Famine-Affected, Refugee, and Displaced Populations:
Recommendations for Public Health Issues

U.S. Department of Health and Human Services
Public Health Service
Centers for Disease Control
Atlanta, Georgia 30333

The MMWR series of publications is published by the Epidemiology
Program Office, Centers for Disease Control, Public Health Service,
U.S. Department of Health and Human Services, Atlanta, Georgia
30333.

Preparing for the health problems experienced by large
populations displaced by natural or man-made disasters is among the
greatest challenges facing public health officials in the world
today. The diversity of problems experienced in long- and
short-term refugee situations demands a diversity of approaches in
disease surveillance, control, and prevention. The Centers for
Disease Control's experience over the past decade has allowed us to
evolve approaches which allow for timely and accurate surveillance
data to be generated even in extremely adverse conditions. The
resulting prevention activities are well focused on the most
important public health problems.

These reports and guidelines have been developed by a number
of CDC professionals working with international organizations and
public health agencies, such as, the Pan American Health
Organization, the United Nations High Commissioner for Refugees,
the United States Agency for International Development, and the
private voluntary organization's of refugee situations. These
reports and guidelines reflect our belief that appropriate,
cost-effective disease prevention technology can be rapidly applied
in most situations that will impact positively the lives of the
affected populations. The recommendations underscore our
organizational interest and commitment to a global health agenda
that will improve the health status of people worldwide.

International disaster preparedness and refugee activities are
collaborative efforts. CDC efforts are performed jointly with many
other governmental, nongovernmental, and international
organizations. It is my hope that public health professionals
involved in dealing with these issues will find this information
useful in their planning, training, and emergency preparedness
efforts.

William L. Roper, M.D., M.P.H., Director
Centers for Disease Control

Foreword

In the past decade, public health emergencies have occured
with great frequency -- and the number of people affected has
captured the attention of the world. Many of these emergencies
involved some degree of forced population migration, and almost all
have been associated with severe food shortages. Natural disasters,
such as droughts and floods, have been partially responsible, but
the most common causes of these emergencies have been war and civil
strife. Since 1984, the number of refugees dependent for their
survival on international assistance has more than doubled to a
current estimate of approximately 17 million persons -- almost all
in
developing countries. Kurdish refugees fleeing Iraq captured the
world's attention briefly in early 1991, but the desperate plight
of many others -- especially the 5 million refugees in Africa --
receives scant attention from the world media. Even more obscure
are the estimated 16-20 million displaced persons who are trapped
within their countries by civil wars and are unable to cross
borders to seek help from the international community. This
situation represents an unprecedented challenge to the
international public health community.

CDC has had a long-standing institutional commitment to the
problem of famine-affected, refugee, and displaced populations for
many years. During the Nigerian Civil War in the 1960s, 20 Epidemic
Intelligence Service officers helped maintain public health
programs for millions of displaced civilians, who were deprived of
their basic needs by that war. Since then, CDC has provided
technical assistance to relief agencies working in most of the
world's major refugee emergency communities including those in, for
example, Ethiopia, Kenya, Malawi, Pakistan, Somalia, Sudan,
Thailand, Turkey, and West Africa. CDC, United Nations agencies,
countries of asylum, and private voluntary organizations (PVOs)
have attempted to adapt traditional epidemiologic techniques and
public health programs to the realities of refugee camps and
scattered, famine-affected communities. As a result, a considerable
body of knowledge and experience has accumulated and has been
documented in various issues of the MMWR. This report represents a
compilation of this knowledge for dissemination and for providing
guidance on certain technical subjects for those involved in future
relief programs.

By necessity, this document is unable to cover all aspects of
emergency relief. The recommendations provided here will not be
effective unless they are supported by adequate preparedness
planning, coordination, communications, logistics, personnel
management, and relief worker training. Even more critical is
ensuring access by relief workers to internally displaced
populations -- many needy communities are caught in areas of
contested sovereignty. Unless the international community can
devise ways of providing assistance to communities in these
circumstances, it will be impossible to implement these basic
public health programs. Finally, the situation of refugees and
displaced persons is a timely reminder of the clear interface
between public health and social justice. The most effective
measure to prevent the high mortality experienced by these
populations would be to eliminate the causes of the violence and
conflict from which they fled.

Joe H. Davis, M.D.
Associate Director for International Health
Director International Health Program Office
Centers for Disease Control

Famine-Affected, Refugee, and Displaced Populations:
Recommendations for Public Health Issues

INTRODUCTION

During the past three decades, the most common emergencies
affecting the health of large populations in developing countries
have involved famine and forced migrations. The public health
consequences of mass population displacement have been extensively
documented. On some occasions, these migrations have resulted in
extremely high rates of mortality, morbidity, and malnutrition. The
most severe consequences of population displacement have occurred
during the acute emergency phase, when relief efforts are in the
early stage. During this phase, deaths -- in some cases -- were 60
times the crude mortality rate (CMR) among non-refugee populations
in the country of origin (1). Although the quality of international
disaster response efforts has steadily improved, the human cost of
forced migration remains high.

Since the early 1960s, most emergencies involving refugees and
displaced persons have taken place in less developed countries
where local resources have been insufficient for providing prompt
and adequate assistance. The international community's response to
the health needs of these populations has been at times
inappropriate, relying on teams of foreign medical personnel with
little or no training. Hospitals, clinics, and feeding centers have
been set up without assessment of preliminary needs, and essential
prevention programs have been neglected. More recent relief
programs, however, emphasize a primary health care (PHC) approach,
focusing on preventive programs such as immunization and oral
rehydration therapy (ORT), promoting involvement by the refugee
community in the provision of health services, and stressing more
effective coordination and information gathering. The PHC approach
offers long-term advantages, not only for the directly affected
population, but also for the country hosting the refugees. A PHC
strategy is sustainable and strengthens the national health
development program.

BACKGROUND
Classification of Disasters

One way of describing the evolution of disasters is in terms
of a "trigger event" leading to "primary effects" and "secondary
effects" on vulnerable groups in the population (2). In the case of
a rapid-onset natural disaster like an earthquake, the primary
effects, deaths and injuries, may be high, but there are few
secondary effects. In the case of slow-onset natural disasters like
drought and manmade disasters, like war and civil strife, the
secondary effects (i.e., decreased food availability, environmental
damage, and population displacement) may lead to a higher delayed
death toll than that of the initial event. Although population
displacement may result from a number of different types of
disasters -- manmade and natural -- the two most common recent
trigger
events have been food deficits and war. In many parts of the world
where food shortages have become common, war and civil strife are
major causative factors. Consequently, war, food deficits, famine,
and population displacement have been inextricably linked risk
factors for increased mortality in certain large populations in
Africa, Asia, Latin America, and the Middle East.

The purpose of this report is to describe the public health
consequences of famine and population displacement in developing
countries and to present the most current recommendations on public
health programs of major importance.
Refugee and Displaced Populations

The 1951 United Nations Convention defines a refugee as "Any
person who owing to a well founded fear of being persecuted for
reasons of race, religion, nationality, membership of a particular
social group or political opinion is outside the country of his
nationality and is unable, or owing to fear is unwilling to avail
himself of the protection of that country; or who, not having a
nationality and being outside the country of his former habitual
residence, is unable, or having such fear is unwilling to return to
it" (3). In 1969, the Organization of African Unity expanded this
definition to include persons fleeing from war, civil disturbance,
and violence of any kind (4).

These definitions, however, exclude persons who leave their
country of origin to seek economic betterment, as well as persons
or groups who may flee their homes for the above or other reasons,
yet remain within the borders of their own country. There are few,
if any, international regulations covering these internally
displaced populations, yet it is estimated that more than half of
all displaced persons worldwide are living within the borders of
their home country (5).
FAMINE-AFFECTED POPULATIONS
Definition and Causes

Famine has been defined as "a condition of populations in
which a substantial increase in deaths is associated with
inadequate food consumption" (6). Famine does not necessarily arise
solely from problems of food production. Natural disasters (e.g.,
drought or crop infestations) may act as triggers, but lack of
sufficient food for consumption may be due to economic collapse and
loss of purchasing power in some sections of the population, (i.e.,
the Indian famine of 1972). In early 1992, efforts to assess the
impact of sudden economic changes in the republics of the former
Soviet Union have focused on income and food price indicators. In
Russia, elderly pensioners were identified as a vulnerable group
among whom the income-to-food cost ratio was estimated to be 1:2 in
mid-January (7). Other causes of famine have included disruption of
food production and marketing by armed conflict (i.e., Biafra in
1968, Sudan in 1988, and Somalia in 1991) and widespread civil
disturbances (i.e., Zaire in 1991).

Famine is usually caused by the amplification of a
pre-existing condition characterized by widespread poverty,
intractable debt, underemployment, and high malnutrition
prevalence. Under these conditions, a large percentage of the
population may routinely experience starvation. When additional
burdens related to the production or availability of food arise,
generalized starvation occurs rapidly. In recent years, frequent
crop failures in Ethiopia, Somalia, Sudan, and the Sahelian
countries of Africa have been attributed to progressive
deterioration of the environment, including deforestation,
desertification, and poor agricultural practices.

Populations experiencing famine may or may not displace
themselves in order to improve food availability. Initially, male
family members may migrate to cities or neighboring countries to
seek employment. During a full-scale famine, whole families and
villages may flee to other regions or countries in a desperate
search for food. In most of the major population displacements of
the past 20 years, however, people have been forced to flee because
of fear for their physical security caused by war or civil strife.
Famine in the absence of violence has generated few of the world's
refugees.

Detection of Famine

Famines are often assessed and reported in terms of cases,
rates, or degrees of malnutrition, or numbers of deaths from
malnutrition. These parameters have been classified as "trailing"
indicators and are not useful for early famine detection and the
initiation of prevention or mitigation measures. More important in
the early detection of famine are "leading" and "intermediate"
indicators that reflect changes in the economic, social, and
environmental factors that influence the evolution of food
shortages and famine.

The leading and intermediate indicators will be useful if they
trigger early interventions aimed at ensuring adequate food
supplies for the population and at maintaining the purchasing power
of vulnerable groups. These measures have included temporary
government subsidies for food crops, "food-for-work" programs;
government-run, fixed-price food shops; rural employment schemes;
the distribution of drought-resistant seeds; and the release of
food reserves.

Effective early warning systems might help avert major
population movements, thereby allowing local government and
international and private voluntary organizations (PVOs) to provide
assistance in situ without major disruption in traditional social
structures and lifestyle patterns. Affected communities can be
surveyed, needy households identified, food and other relief
supplies distributed, and major epidemics averted with greater ease
and effectiveness in a stable population than in a temporary
refugee settlement. National early warning systems have proved
effective in preventing famine during the past decade in India and
Botswana (8). When populations are forced to migrate en masse, they
usually end up in camps or urban slums characterized by
overcrowding, poor sanitation, substandard housing, and limited
access to health services. These conditions hamper the effective
and equitable distribution of relief supplies and promote the
transmission of communicable diseases.

REPORTS

The most direct and obvious results of famine are severe
undernutrition and death. While longitudinal studies have
demonstrated that undernourished persons -- particularly children
--
are at higher risk of mortality, the immediate cause of death is
usually a communicable disease. Malnutrition causes an increased
case-fatality ratio (CFR) in the most common childhood communicable
diseases (i.e., measles, diarrheal disease, malaria, and acute
respiratory infections (ARIs)). Those at highest risk of mortality
during nonfamine times -- namely, the poor, the elderly, women, and
young children -- are the same groups most at risk for the
morbidity
and mortality caused by famine. In addition, the movement of
populations into crowded and unsanitary camps, the violence
associated with forced migrations, and the negative psychological
effects of fear, uncertainty, and dependency contribute to the
health problems experienced by displaced persons.
Mortality

Mortality rates are the most specific indicators of the health
status of emergency-affected populations. Mortality rates have been
estimated retrospectively from hospital and burial records, or from
community-based surveys, and prospectively from 24-hour burial site
surveillance. Among the many problems encountered in estimating
mortality under emergency conditions are recall bias in surveys,
families' failure to report perinatal deaths, inaccurate
denominators (overall population size, births, age-specific
populations), and lack of standard reporting procedures. In
general, bias tends to underestimate mortality rates, since deaths
are usually underreported or undercounted, and population size is
often exaggerated. Most reports of famine-related mortality have
come from populations that have experienced considerable
displacement. It is possible that mortality rates are lower in
those populations that remain in their original villages and homes.
A comparison of mortality in displaced vs. nondisplaced,
famine-affected populations is problematic because displacement
itself may reflect a more serious baseline situation. Nonetheless,
comparisons between displaced and nondisplaced populations during
famine on one hand, and between refugees and local, host country
populations on the other hand, show that in nearly all cases the
displaced and refugee populations experience a markedly higher CMR.

The CMRs reported in various refugee, internally displaced,
and famine-affected (but nondisplaced) populations, respectively,
during the emergency phase of relief operations in the past 15
years are listed in Tables 2, 3, and 4. These rates are compared
with baseline CMRs reported for nonfamine-affected and nondisplaced
populations, or, in the case of refugees, with CMRs in their
country of origin. CMRs in these tables are expressed as deaths per
1,000 per month to reflect the short reporting periods; comparison
rates have been extrapolated from annual CMRs published by the
United Nations Children's Fund (UNICEF) (13). Although CMRs
reported in refugee emergencies have not been adjusted for age and
sex, it is unlikely that demographic differences between refugee
and non-refugee populations account for the excess mortality found
among many of the latter.

Monthly CMRs recorded immediately after the initial influx of
Cambodian refugees into Thailand (1979), Ethiopian refugees into
Somalia (1980), and Ethiopian refugees into eastern Sudan (1985)
were 8.1 to 15.2 times the expected rates. The early death rate
among Kurdish refugees in Turkey in April 1991 was 18 times the
baseline rates in both Iraq and Turkey. In contrast, among
Mozambican refugees in Malawi in 1987, camp-based CMRs were
one-third lower than the national CMR reported for Mozambique. A
movement of 50,000 refugees from Burundi into Rwanda in 1988 also
resulted in minimal mortality once asylum had been attained. The
rate of improvement in camp populations has varied considerably.
For example, mortality rates decreased rapidly in Cambodian refugee
camps in Thailand in 1979-1980 and in the Kurdish camps of Turkey
in 1991, but only slow improvement occurred during the initial 8
months in Somalia (1980) and in Sudan (1985). In eastern Ethiopia
in 1988-1989, initially low mortality rates among Somali refugees
increased after 6 months, reaching a peak at 9 months (Figure 3).
Overall, less than 1% of Cambodian refugees in Thai camps died
during the first 12 months; 9% of refugees in eastern Sudan died
during the same period of time (1).

Political and security factors often obstruct the accurate
documentation of death rates among internally displaced
populations; however, a few situations have been well documented.
In Mozambique (1983), Ethiopia (1984-1985), and Sudan (1988), CMRs
estimated by surveillance or population-based surveys of internally
displaced persons ranged between 4 and 70 times the death rates in
nondisplaced populations in the same country. In the Korem area of
Ethiopia, CMRs recorded among camp populations displaced by famine
in 1985 were 7-10 times those of settled villagers in a similar
highland zone affected by the famine. In Monrovia, the capital of
Liberia, the death rate among civilians displaced during the 1990
civil war was 7 times the pre-war death rate (Holland MSF,
unpublished data, January 1991).

As in stable populations in developing countries, age-specific
death rates in displaced and refugee populations are highest in
children less than 5 years of age. A mortality survey of Kurdish
refugees at the Turkey-Iraq border during 1991 revealed that 63% of
all deaths occurred among children less than 5 years of age, who
comprised approximately 18% of the population (11). Although
absolute death rates are highest in infants less than 1 year of
age, the relative increase in mortality during emergencies may be
highest in children 1-12 years of age (1).

Cause-specific mortality

The major reported causes of death in refugee and displaced
populations have been those same diseases that cause high death
rates in nondisplaced populations in developing countries:
malnutrition, diarrheal diseases, measles, ARIs, and malaria. These
diseases consistently account for 60%-95% of all reported causes of
death in these populations (Figures 4, 5, and 6). Specific reports
on these and other communicable diseases are presented in a later
section. In those situations where malnutrition was not classified
as an immediate cause of death (i.e., Sudan and Somalia), it was a
major underlying factor accounting for the high CFRs from
communicable diseases. This synergism between high malnutrition
prevalence and increased incidence of communicable diseases
explains much of the excess mortality seen in refugee and displaced
populations.

A study of 42 refugee populations completed in 1989 examined
acute protein energy malnutrition (PEM) prevalence and crude
unadjusted monthly mortality rates, gathered from 1984-1988.
Analysis of the data showed a strong positive association between
PEM prevalence and CMRs. Populations with PEM prevalence rates of
less than 5% had a mean CMR of 0.9/1,000/month. Refugee populations
with PEM prevalences of greater than or equal to 40%, however,
experienced a mean CMR of 37/1,000/month with a range of
4/1,000/month to 177/1,000/month (Figure 7). The rate ratio between
the lowest and highest CMR values was 40.7 (14).

The close correlation between malnutrition prevalence and
crude mortality during a relief operation for Somali refugees in
eastern Ethiopia in 1988-1989 is clearly demonstrated in Figure 8.
Malnutrition prevalence was estimated by serial, cross-sectional,
cluster sample surveys of children less than 5 years of age, and
monthly death rates were estimated retrospectively by a
population-based survey in August 1989. During the period of high
malnutrition prevalence and high mortality (March-May 1989), food
rations provided an average of approximately 1,400 kilocalories
(kcal)/person/day instead of the recommended minimum of 1,900
kcal/person/day (9). Likewise, in eastern Sudan in 1985, inadequate
amounts of food (1,360-1,870 kcal/person/day) were distributed to
Ethiopian refugees during the first 5 months after their arrival in
the camps. Malnutrition rates, as well as mortality rates, remained
high during this period (Figure 3) (Table 5). In addition, a severe
measles outbreak in the Sudanese camps added to the high mortality
(21).

Nutritional Diseases
Protein-energy malnutrition

PEM can refer to either acute or chronic undernutrition.
Because children less than 5 years of age are among the most
acutely affected by undernutrition, assessment of this age group by
anthropometry is usually done to determine PEM prevalence in a
population (see "Indicators of Acute Undernutrition"). In general,
acute undernutrition results in wasting and is assessed by an index
of weight-for-height (WFH); however, edema of the extremities may
be associated with acute undernutrition in which case, a clinical
assessment is necessary. Chronic undernutrition produces stunting
and typically results in a diminished height-for-age index.

The prevalence of moderate to severe acute undernutrition in
a random sample of children less than 5 years of age is generally
a reliable indicator of this condition in a population. Since
weight is more sensitive to sudden changes in food availability
than height, nutritional assessments during emergencies focus on
measuring WFH. Also, WFH is a more appropriate measurement for
ongoing monitoring of the effectiveness of feeding programs. As a
screening measurement, the mid-upper arm circumference (MUAC) may
also be used to assess acute undernutrition, although there is not
complete agreement on which cutoff values should be used as
indicators. Nutritional assessment methods are fully described in
the Rapid Nutrition Assessment Manual. *

Anthropometric indices such as WFH and height-for-age are
interpreted by comparison with a "reference population". Index
values are assigned a "Z-score" based on the number of standard
deviations above or below the median value in the reference
population. Currently, the World Health Organization (WHO)
recommends the use of the CDC/NCHS reference population for
nutritional assessments in all countries (22). Before the
mid-1980's, anthropometric data was reported as a percentage of the
median of the reference population value. Current international
guidelines, however, recommend the use of Z-scores to report
nutritional assessment data. Tables in this report define acute
undernutrition on the basis of percentage median in order to allow
comparisons of recent data with data from surveys performed before
the mid-1980s.

In a well-nourished population in which WFH values are
distributed normally (i.e., the reference population),
approximately 3% of children less than 5 years of age will have WFH
Z-scores of less than -2. For less developed countries with lower
"normal" nutritional intake levels, 5% of the children may have a
Z-score less than -2 when compared with the reference population
median, particularly at certain times of the year. Relief
organizations agree that a nutritional emergency exists if greater
than 8% of the children sampled have a Z-score less than -2. An
excess of even 1% of children with Z-scores less than -3 indicates
a need for immediate action. Acute PEM prevalence rates have been
high in recent famine-affected populations, especially in Africa
(Table 6).

In addition, acute undernutrition prevalence rates have been
elevated in many displaced and refugee populations during the past
12 years, ranging as high as 50% in eastern Sudan in 1985 (Tables
5 and 7). PEM rates have decreased rapidly in situations where
effective emergency relief operations have been mounted promptly,
i.e., Thailand (1979) and Pakistan (1980). However, in other
emergencies, such as in Somalia (1980) and Sudan (1985), PEM rates
have remained high (greater than 20%) for 6-8 months. Of even
greater concern is the observation that acute undernutrition rates
among Somali refugees in Ethiopia (1988-1989) actually increased 6
months after a relief program was launched. Although most high
acute undernutrition prevalence has been associated with inadequate
food rations, it appears that malnutrition developed among Kurdish
children 1-2 years of age in Turkey within a period of 1-2 months,
primarily because of the high incidence of diarrheal diseases in
the camps (10). Among internally displaced civilian populations,
high PEM prevalence has been associated with the intentional use of
food as a weapon by competing military forces (30).

The use of serial anthropometry surveys as monitoring tools
has certain limitations when mortality rates are high. For example,
an analysis of anthropometric data from two cross-sectional surveys
in a refugee camp in Sudan in 1985 initially implied a relatively
stable nutritional situation. In January, the prevalence of acute
malnutrition in children less than 5 years of age was 26.3%; in
March, the rate was 28.4%. During these two months, almost 13% of
the children in the camp died, mainly from measles and diarrheal
diseases. In this instance, the elevated child mortality rate
masked diminished nutritional status in the population. Many
malnourished children in the first survey, who had died, were
"replaced" in the second survey sample by surviving children whose
nutritional status had meanwhile deteriorated (31). Thus,
anthropometry data need to be interpreted in the context of
concurrent mortality rates.

Micronutrient deficiency diseases

In addition to PEM, micronutrient deficiencies play a key role
in nutrition-related morbidity and mortality. The importance of
micronutrient deficiencies in famine-affected and displaced
populations has recently been extensively documented. In addition
to deficiencies of vitamin A and iron, conditions widely recognized
as important childhood problems in developing countries (i.e.,
epidemics of scurvy and pellagra) have also been reported in
refugee populations during the past decade (Table 8).

Vitamin A deficiency

The most common deficiency syndrome in emergency affected
populations is caused by lack of vitamin A. Ocular signs of vitamin
A deficiency -- known as xerophthalmia -- include night blindness
and
Bitot's spots in the earlier stages. Xerophthalmia progresses to
corneal xerosis, ulceration and scarring, and eventually blindness.
Signs of xerophthalmia were detected in 7% of children surveyed in
one region of Somalia during the drought of 1986-1987 (27); 2.1% in
drought-affected Niger in 1985 (24); 4.3% among Kampuchean refugees
in Thailand (36); and 2.7% in a region of Mauritania in 1984 (23).
Recent data suggest that vitamin A deficiency is linked with high
childhood mortality (37-38).

Famine-affected and displaced populations often have low
levels of dietary vitamin A intake before experiencing famine or
displacement, and therefore, may have very low vitamin A reserves.
Furthermore, the typical rations provided in large-scale relief
operations lack vitamin A, putting these populations at high risk.
In addition, some communicable diseases that are highly incident in
refugee camps -- measles and diarrheal diseases -- rapidly deplete
vitamin A stores. Depleted vitamin A stores need to be adequately
replenished during recovery from these diseases to prevent the
deficiency from becoming clinically important.

Vitamin C deficiency (scurvy)

Although scurvy has been reported rarely in stable populations
in developing countries, many outbreaks have occurred in displaced
and famine-affected populations in recent years, primarily because
of inadequate vitamin C in rations. In 1981-1982, an outbreak of
more than 2,000 cases of scurvy occurred in the refugee camps of
the Gedo region of Somalia. These Ethiopian refugees had
traditionally obtained sufficient dietary vitamin C from camel's
milk. Once in refugee camps they subsisted on a ration devoid of
vitamin C. The outbreak was precipitated when local markets, where
refugees had exchanged rations for fresh fruit and vegetables, were
suddenly closed (39).

Active surveillance for scurvy among Ethiopian refugees in
Somalia and Sudan in 1987 revealed cumulative incidence rates of up
to 19.8% in some camps, with initial onset reported between 3-10
months after the arrival of the refugees (32). Cross-sectional
surveys performed in 1986-1987 reported point prevalence rates as
high as 45% among females and 36% among males; prevalence increased
with age. The prevalence of scurvy was associated with the period
of residence in camps, and the time exposed to rations lacking in
vitamin C. In 1989, a population survey of children less than 5
years of age in Hartisheik camp in eastern Ethiopia in 1989 found
the prevalence of clinical scurvy to be 2% (19). The international
community has not developed an adequate strategy to prevent scurvy
in refugee camps at the Horn of Africa, as demonstrated by an
outbreak that took place among adult males (former Ethiopian
soldiers) in a camp in eastern Sudan during 1991 (Bhatia R,
personal communication, October 1991).

Niacin deficiency

Pellagra is the condition resulting from a severe deficiency
of biologically available niacin in the diet. Once common in the
southeastern United States, Italy, and Spain, pellagra now occurs
mainly in maize- or sorghum-consuming populations in southern
Africa, North Africa, and India. An outbreak of pellagra occurred
in Malawi among Mozambican refugees between July and October 1989.
Eleven camps reported a total of 1,169 patients; 20% of the
patients were children less than 5 years of age (40). The French
agency Medecins Sans Frontieres (MSF) instituted active
surveillance at the time. Another outbreak occurred between
February and October 1990 with 17,878 cases reported among 285,942
refugees in the same 11 sites (attack rate of 6.3%). More than
18,000 cases of deficiency were reported from all districts hosting
approximately 900,000 refugees in southern Malawi, for an overall
attack rate of 2.0% (35). Food rations contained an average of 4.9
mg of available niacin/person/day; the Food and Agriculture
Organization (FAO)/WHO recommendations for daily niacin intake
range from 5.4 mg for infants to 20.3 mg for adults. This outbreak
occurred when relief efforts failed to include an adequate supply
of groundnuts (peanuts), the major source of niacin in refugee
rations. The lack of variety in basic relief rations is a major
risk factor for pellagra and other micronutrient deficiency
syndromes. Treatment of maize flour with lime (which converts
niacin to a biologically available form of niacin) and the
inclusion of beans, groundnuts, or fortified cereals in daily
rations increase the total intake of available niacin and will
prevent the development of pellagra (35).

Anemia

The high prevalence of anemia in refugee and displaced
populations has been noted in few publications to date, but
unpublished data from CDC assessments suggest that it may be a
serious problem in some areas. In 1990, a survey of Palestinian
refugees in Syria, Jordan, and the West Bank revealed that the
prevalence of anemia among infants and young children was between
50% and 70%. Anemia among both nonpregnant and pregnant women was
shown to be 25%-50%, whereas a low anemia prevalence rate was found
among the male population. (In this study anemia was defined as a
hemoglobin concentration of less than 11 g/dL among children and
less than 12 g/dL among nonpregnant women. Pregnant women were
considered to be anemic if their hemoglobin concentration was less
than 11.5 g/dL during either the first or third trimester, or less
than 11.0 g/dL during the second trimester.) These findings suggest
that iron deficiency, which preferentially affects women and
children, was the primary cause of anemia in this population.

A 1987 study among refugees in Somalia demonstrated an anemia
prevalence rate of 44%-71% among pregnant women, with that
proportion being even greater if only women in the third trimester
of pregnancy were considered. The cutoff point for hemoglobin
concentration in this study was 10 g/dL; with the WHO cutoff of 11
g/dL, the prevalence would have been greater. Among children 9-36
months of age, 59%-90% were below the 10 g/dL cutoff. The
inadequacy of the general ration was identified as the major factor
causing iron deficiency anemia in this population. In a 1990 study,
the prevalence rate of anemia was 13% among children less than 5
years of age in an Ethiopian camp for Somali refugees (Save the
Children Fund UK, unpublished data). In addition to dietary iron
deficiency, the high incidence of malaria in many refugee
populations probably contributes to the high prevalence of anemia
in children. This high prevalence of anemia found in some refugee
populations may not be significantly greater than that found in
local, non-refugee populations, since the latter group has been
poorly documented. Nevertheless, anemia may be an additional
important preventable risk factor for high mortality in refugee
populations. The high prevalence of anemia is often correlated with
a subset of the population with severe anemia (hemoglobin (Hb) less
than 5 g). Severe anemia in itself can be a major cause of
mortality for young children and pregnant women during the
peripartum period.

Other micronutrient deficiencies

Beriberi (thiamine deficiency) has been reported from several
refugee populations that subsist on rice-based food rations
(Thailand, 1980; Guinea, 1990). Data regarding iodine deficiency in
displaced populations are difficult to find, anecdotal evidence
suggests that iodine deficiency, as evidenced by the presence of
goiter, has been a problem in at least some camps in Pakistan and
Ethiopia (CDC. Toole M, trip report, 1991).

Communicable Diseases

Measles, diarrheal diseases, ARIs, and in some cases, malaria
are the primary causes of morbidity and mortality among refugee and
displaced populations (1,16,41). Figures 4-6 illustrate patterns of
mortality typical among those found in refugee camps. Other
communicable diseases, i.e., meningococcal meningitis, hepatitis,
typhoid fever, and relapsing fever have also been observed among
refugee populations; however, the contribution of these illnesses
to the overall burden of disease among refugees has been relatively
small.

Densely populated camps with poor sanitation, inadequate clean
water supplies, and low-quality housing all contribute to the rapid
spread of disease in refugee settings. In addition, the interaction
between malnutrition and infection in these populations,
particularly among young children, has contributed to the high
rates of morbidity and mortality from communicable diseases.
Available and affordable technology could prevent much of this
morbidity and mortality either through primary prevention (e.g.,
immunization, adequate planning, and sanitation) or through
appropriate case management (e.g., treatment of dehydration caused
by diarrhea with oral rehydration salts and continued feeding).

Measles

Outbreaks of measles within refugee camps have been common and
have caused many deaths. Low levels of immunization coverage,
coupled with high rates of undernutrition and vitamin A deficiency,
have played a critical role in the spread of measles and the
subsequent mortality within some refugee camps. Measles has been
one of the leading causes of death among children in refugee camps.
In addition, measles has contributed to high malnutrition rates
among those who have survived the initial illness. Measles
infection may lead to or exacerbate vitamin A deficiency,
compromising immunity and leaving the patient susceptible to
xerophthalmia, blindness, and premature death (42). In early 1985,
the crude, measles-specific death rate in one eastern Sudan camp
reached 13/1,000/month; among children less than 5 years of age,
the measles-specific death rate was 30/1,000/month. Over 2,000
measles deaths were reported in this camp from February through May
1985. Figure 9 illustrates the proportion of all deaths that were
due to measles in this camp during the course of the outbreak (16).
The CFR was reported to be 33% during this outbreak; however, mild
cases may have been underreported. Large numbers of measles deaths
have been reported in camps in Somalia, Bangladesh, Sudan, and
Ethiopia (1). Mass immunization campaigns were effective in
reducing the measles morbidity and mortality rates in camps in both
Somalia and Thailand (16). Measles outbreaks probably did not occur
during certain other major refugee emergencies (e.g., Somalis in
Ethiopia in 1989; Iraqis in Turkey in 1991), because immunization
coverage rates were already high in those refugee populations
before their flight (9,10).

Diarrheal diseases

Diarrheal diseases are a major cause of morbidity and
mortality among refugee and displaced populations, primarily
because of the inadequacy of the water supply (both in terms of
quality and quantity), and the insufficient and poorly maintained
sanitation facilities. In eastern Sudan in 1985, between 25%-50% of
all deaths in four major camps were attributed to diarrheal
diseases. In Somalia (1980), Malawi (1988), and Ethiopia (1989),
between 28%-40% of all deaths in refugee camps were attributed to
diarrhea (1). Between March and October 1991, 35% of deaths among
Somali refugees in the Liboi camp in Kenya were caused by diarrhea.
Among Central American refugees in Honduras, diarrheal diseases
were responsible for 22.3% of mortality among children less than 5
years of age during a 3-year period (43). In April 1991, in camps
for Iraqi refugees on the Turkish border, approximately 70% of all
patients arriving at clinics had diarrhea (10). Of these,
approximately 25% complained of bloody diarrhea during the first 2
weeks of April. Figure 10 shows the gradual decline in diarrheal
disease among clinic outpatients at a Kurdish refugee camp in
Turkey.

Improvements in camp sanitation and water supply were probably
responsible for this trend. Although the etiologies of diarrheal
illness during refugee emergencies have not been well documented,
the responsible pathogens are most likely to be the same agents
that cause diarrhea in non-refugee populations in developing
countries. In one study in a camp for famine victims in Ethiopia,
of 200 patients with diarrhea, 15.6% had positive cultures for
Escherichia coli (pathogenicity not specified by authors), 3.5% for
Shigella spp., and 2% for Salmonella spp. (44).

Cholera

Outbreaks of cholera have occurred in several refugee
populations, although overall, other diarrheal diseases have
probably caused many more deaths than cholera. In addition to the
morbidity and mortality directly caused by cholera, epidemics of
this severe disease cause serious disruption to camp health
services. Outbreaks of cholera have been reported in refugee camps
in Thailand (16,45), Sudan (46), Ethiopia (11-12), Malawi (47),
Somalia (48), and Turkey (10). The Somali Refugee Health Unit
reported 6,560 cases of cholera and 1,069 cholera deaths in 1985.
During the course of the epidemic, one camp (Gannet) experienced a
CFR of 25%. The CFR in the remaining camps was 2.9%, with some
areas reporting a CFR of less than 1% (Figure 11) (48). During the
same year, two adjacent refugee camps in the Sudan reported a total
of 1,175 cases of cholera with 51 deaths (CFR = 4%) over the course
of a 2-week epidemic (46). Mozambican refugees in Malawi have been
especially vulnerable to cholera; 20 separate outbreaks have been
reported in Malawian camps since 1988 (49). Outbreak investigations
have identified polluted water sources, shared water containers and
cooking pots, lack of soap, failure to reheat leftover food, and
possibly contaminated food (dried fish) as important risk factors
for infection. Nearly 2,000 cases were reported among 80,000
refugees in one camp (Nyamithutu) during a 4-month period in 1990
(Figure 12). Among 26,165 new arrivals during this period, 1,651
cases were reported for an attack rate of 6.3% in this group. The
variation in CFRs between camps reflects the different levels of
organizational preparedness, health worker training and experience,
and available resources. One group of relief workers speculated
that high CFRs in some Malawian camps may be associated with
concurrent niacin deficiency, although their hypothesis has not yet
been proven (Moren A, personal communication).

Acute respiratory infections

ARIs are among the leading causes of death among refugee
populations. In Thailand (1979), Somalia (1980), Sudan (1985), and
Honduras (1984-1987), ARIs were cited among the three main causes
of mortality in refugee camps, particularly among children (16,43).
Among children less than 5 years of age in refugee camps in
Honduras, respiratory infections were responsible for slightly
greater than 1 of every 5 deaths during a 3-year period (43).

Tuberculosis (TB)

TB is well recognized as a health problem among refugee
populations. The crowded living conditions and underlying poor
nutritional status of refugee populations may foster the spread of
the disease. Although not a leading cause of mortality during the
emergency phase, TB often emerges as a critical problem once
measles and diarrheal diseases have been adequately controlled. For
example, 26% of adult deaths among refugees in Somalia in 1985 were
attributed to TB (16). During this time, TB was the third leading
cause of death, and the leading cause among adults (48). In eastern
Sudan, between 38% and 50% of all deaths in two camps were caused
by TB during the 9 to 10 months period after the camps opened (16).
TB has been cited as a major health problem among Afghan refugees
in Pakistan (CDC. Serdula M, trip report). Although it may be
theoretically easier to ensure patient compliance with protracted
chemotherapy in the confined space of a refugee camp, the personnel
needed to supervise treatment may not be available. In addition,
the uncertain duration of stay, frequent changes of camp locations,
and poor camp organization may hinder TB treatment programs.

Malaria

Malaria is a major health problem in many areas that host
large refugee populations, including Somalia, Sudan, Ethiopia,
Thailand, Guinea, Cote d'Ivoire, Malawi, Pakistan, and Kenya.
Malnutrition and anemia, conditions that are common among refugees,
may be directly related to recurrent or persistent malaria
infection or may compound the effects of malaria and lead to high
mortality. Malaria is the leading cause of morbidity among adult
refugees in Malawi and in 1990 caused 18% of all deaths and 25% of
deaths among children less than 5 years of age (CDC, unpublished
data). Malaria is of particular concern when the displaced
population has traveled through, or into, an area of higher
endemicity than its region of origin (1). During the period 1979-
1980, Khmer refugees traveled from the central valley of Kampuchea,
where malaria transmission is very low, into Thailand. Those
refugees who arrived at the Sakaeo camp traveled through mountain
regions where malaria is highly endemic year round, while refugees
who arrived at Khao I-Dang camp had traveled a route that remained
within the areas of low malaria transmission. As a result of the
differences in exposure during transit, the initial malaria
prevalence rate at Sakaeo was 39% compared with a 4% prevalence
rate at Khao I-Dang. During this time, malaria was a major cause of
death at Sakaeo (50). Similarly, Ethiopian refugees from the
highland areas of Tigray province arrived in eastern Sudan in 1985
with decreased immunity against the malaria that is seasonally
endemic in that region of Sudan. Not surprisingly, malaria was an
important cause of death among these refugees. Farther north, in
the Kassala region of eastern Sudan, a major outbreak of malaria
occurred among refugees from Eritrea following extensive flooding
in the area in September 1988. In contrast to the Tigrayan
refugees, the Eritreans were largely from lowland areas and had
been previously exposed to malaria. The severity of this outbreak
may have been due to the emergence of chloroquine resistant
Plasmodium falciparum malaria in eastern Sudan at that time, and
the subsequent widespread failure of first-line treatment regimens
(Toussie S, personal communication, 1989).

Afghan refugees living in the North-West Frontier Province of
Pakistan have a higher incidence of clinical malaria than that
observed among the local population. A comparison of the
epidemiologic trends of malaria between the refugees and the local
population over a period of several years demonstrated that the
increased rate of malaria illness among refugees was a result of
having resettled in an area of higher transmission than that from
which they had fled. Because of their limited exposure history, the
Afghan refugees had lower levels of immunity to malaria illness
than did the local population (51). Few deaths associated with
malaria have been reported in this population because the majority
of cases have been associated with Plasmodium vivax, a milder form
of malaria than that caused by Plasmodium falciparum, the form that
is more commonly reported in African camps.

Hepatitis

Hepatitis has not been among the most common diseases reported
in refugee and displaced populations worldwide, however, since 1985
it has emerged as a serious problem in camps at the Horn of Africa,
where access to adequate supplies of clean water has been severely
limited. In Somalia during the period 1985-1986, an outbreak of
greater than 2,000 cases occurred in two refugee camps, with an
overall attack rate of 8% among adults. Of 87 hepatitis deaths, 46%
were among pregnant women. The overall CFR was 4%, the CFR in
second- and third-trimester pregnant women was 17%. By a process of
exclusion, the outbreak was attributed to enterically transmitted
non-A, non-B hepatitis (now known as hepatitis E) (52). Figure 13
depicts an outbreak of hepatitis that occurred in the Hartisheik
refugee camp in Ethiopia between 1989 and 1990.

During an 18-month period, greater than 6,000 cases were
reported. Between March and October of 1991, a major outbreak of
hepatitis occurred among Somali refugees living in Kenya's Liboi
camp; a total of 1,700 cases were reported, yielding an attack rate
of 6.3%. The overall CFR was 3.7% and in pregnant women the CFR was
14%. Hepatitis was responsible for one of every five deaths in the
camp during that time period. The hepatitis E virus was identified
in stool and serum specimens from ill patients. The Ethiopian and
Kenyan outbreaks were associated with inadequate water supply. In
both camps, refugees had access to an average of only 1-3 liters of
clean water/person/day (the United Nations High Commissioner for
Refugees (UNHCR) recommends a minimum of 15 liters/person/day)
(53).

Meningitis

Overcrowding and limited access to medical care are
contributing factors in outbreaks of meningococcal meningitis among
refugee populations. Also, many large refugee populations are found
in what is termed the "meningitis belt" of sub-Saharan Africa.
Although children less than 5 years of age are at greatest risk for
meningitis, meningococcal meningitis also occurs among older
children and adults, particularly in densely populated settings
i.e., refugee camps (54). During an outbreak of group A
meningococcal disease at the Sakaeo refugee camp in Thailand in
1980, children less than 5 years of age experienced a CFR of 50%.
The overall CFR during that outbreak was just over 28% (55).
Outbreaks of meningococcal meningitis have also been reported among
Ethiopian refugees in eastern Sudan (1985) and among displaced
Sudanese in Khartoum and southern Sudan during 1988 (56).

Other Health Issues

Although these reports focus on the major causes of morbidity
and mortality during the emergency phase of refugee displacements,
other health problems warrant the attention of public health
practitioners in these settings.

Injuries

Thus far, injuries related to armed conflict and psychological
problems relating to war, persecution, and the flight of the
refugee have been poorly quantified. In a recent report on Iraqi
refugees on the Turkish border, 8% of the deaths during a 2-month
period were attributed to trauma. Sixty percent of these
trauma-related deaths were attributable to shootings by armed
soldiers (CDC. Toole M, trip report, September 1991). Anecdotal
reports support the existence of high rates of physical
disabilities caused by war injuries in some refugee camps, such as
those for Afghan refugees in Pakistan, Cambodian refugees in
Thailand, and Mozambican refugees in Malawi.

Maternal health

The problem of morbidity and mortality related to pregnancy
and childbirth has been inadequately documented, although earlier
sections of this report described high anemia rates and high
hepatitis-specific mortality rates among pregnant women (52). Also,
studies of scurvy and pellagra among refugees in Africa have
consistently revealed higher incidence rates in women than in men,
and a study in Somalia showed that pregnancy was a risk factor for
the development of clinical scurvy (32,35).

Sexually transmitted diseases and HIV

Few published reports have referred to sexually transmitted
diseases (STD) in refugee populations. However, there is no
evidence that the incidence of STDs in camps is any higher (or
lower) than in non-refugee communities. Similarly, practically no
data exist on the prevalence of HIV infection, nor on rates of
transmission in these populations. Many of the large displaced and
refugee populations of the world are either located in, or have
fled to, countries where HIV prevalence rates are high. These
include: Mozambican refugees in Malawi, Zambia, and South Africa;
Ethiopian refugees in Sudan; Liberian refugees in Cote d'Ivoire and
Guinea; Ugandan and Rwandan refugees in Zaire; Cambodian and
Laotian refugees in Thailand; and Sudanese refugees in Uganda.

8. United Nations Administrative Committee for Coordination,
Subcommittee on Nutrition, and the International Nutrition Planners
Forum. Nutrition in times of disaster. Presented as a report of an
international conference; September 27-30, 1988; Geneva,
Switzerland.

The technical recommendations in this report focus on the
public health elements of an appropriate response program for
refugees and displaced persons, however, the effectiveness of
relief efforts will be enhanced if the affected communities and
host countries have prepared for the emergency. Preparedness for
sudden population displacement is critical and should be targeted
at the most important public health problems identified in previous
emergencies: malnutrition, measles, diarrheal diseases, malaria,
ARI, and other communicable diseases (e.g., meningitis and
hepatitis) that result in high death rates.

Preparedness requires that planning for emergencies be
included as an integral part of routine health development programs
in countries where sudden population displacements might occur.
These programs include:

Health Information Systems (HIS).

Diarrheal Disease Control Programs.

Expanded Programs on Immunization (EPI).

Control Programs for Endemic Communicable Diseases.

Nutrition Programs.

Continuing Education Programs for Health Workers.
National public health programs should include detailed

contingency planning for sudden population movements, both
internally and from neighboring countries.

Response Preparedness

The critical components of a relief program responding to
sudden population displacement comprise the provision of adequate
food, clean water, sanitation, and shelter. In addition, the
following elements of a health program should be established as
soon as possible.
Health Information System

Mortality surveillance

Nutrition surveillance

Surveillance for diseases of public health importance

Diarrheal Disease Control

ORT

Community hygiene education

Cholera preparedness

Immunization

Measles immunization immediately

Other EPI antigens later, when the emergency subsides

Identification of sources for meningitis vaccine

Basic Curative Care

Emphasis on maternal and child health (MCH)

Establishment of a referral system

Development of an essential drugs list

Preparation of standard treatment guidelines (at least for

Diarrhea, malaria, and ARI)

Selection, training, and deployment of community health

workers

Endemic disease control and epidemic preparedness

Establishment of surveillance, including standard case

definitions

Development of standard case management protocols

Agreement on policies for prevention (including vaccination

and prophylaxis)

Identification of laboratory to confirm index cases of

epidemic diseases

Identification of sources of relevant vaccines

Establishment of reserves of essential medical supplies

(ORT, intravenous (IV) solutions)

Identification of treatment sites, triage system, and

training needs

Identification of expert assistance for epidemic

investigation

Development of environmental management plans

Implementation of community education and prevention

programs

The detailed recommendations that follow are organized
according to either disease group (e.g., diarrheal diseases or
malnutrition) or technical methods (e.g., rapid assessment).
Nevertheless, it is critical to keep in mind the demographic groups
that are most at risk during emergencies, namely young children and
women. It is important that health services in refugee settings be
organized in a way that facilitates access by these groups. In
general, MCH services should be given higher priority than general
outpatient dispensaries and hospitals.

Maternal and Child Health Care

MCH clinics should be established (ideally one MCH clinic per
5,000 population) and staffed by trained personnel to provide
routine screening and preventive, and curative services to pregnant
and lactating women and to children less than 2 years of age. If
resources are adequate, these services should be extended to
children between 2 and 5 years of age. Services for children should
include routine growth monitoring, immunization, nutritional
rehabilitation, vitamin A supplementation, and curative care, as
well as health education for their mothers.

Female health workers should be trained and employed to
provide culturally appropriate health education both at MCH clinics
and within the community, and to refer pregnant women to the clinic
for antenatal care. At least some of these health workers should be
recruited from among traditional birth attendants in the community.
Antenatal care should include screening for high-risk pregnancies
and providing iron and folic acid supplementation (as well as
iodine supplementation in areas of endemic goiter), tetanus toxoid
immunization, and health education. Postnatal care should include
nutritional supplementation, counselling on family spacing,
provision of contraceptives, and education about breastfeeding and
infant care. In certain cultural situations, curative care may need
to be provided to all women of child-bearing age in a setting
physically segregated from male outpatient facilities.

Program-Specific Recommendations

The following content areas are covered in these
recommendations:

Rapid Health Assessment

Health Information Systems

Nutrition

Control of Vaccine-Preventable Diseases

Control of Diarrheal Diseases

Malaria Control

Tuberculosis Control

Epidemic Investigations

Rapid Health Assessment

Rapid health assessment of an acute population displacement is
conducted to:

Assess the magnitude of the displacement.

Determine the major health and nutrition needs of the

displaced population.

Initiate a health and nutrition surveillance system.

Assess the local response capacity and immediate needs.

Preparations

The amount of time required to conduct an initial assessment
of a refugee influx depends on the remoteness of the location,
availability of transport, security situation in the area,
availability of appropriate specialists, and willingness of the
host country government to involve external agencies in refugee
relief programs. In small countries with functioning communications
facilities and secure borders, the assessment might be conducted in
4 days; in other countries, it might take 2 weeks.

Before the field visit, relevant information relating to the
status of the incoming refugees, as well as the available resources
of the host community, should be obtained from local ministries or
organizations based in the capital city. Any maps of the area where
the refugees are arriving and settling should likewise be obtained.
Aerial photographs will also be of value, but may be considered
sensitive by the military of the host country. International
organizations like UNICEF, WHO, and the Red Cross/Red Crescent may
also have demographic and health data concerning the refugee
population.

In preparation for the field visit, establish whether food,
medical supplies (including vaccines), or other relief supplies
have been ordered or procured by any of the relief agencies
involved. Additionally, the following conditions should be included
in a field assessment.

Field assessment

The following demographic information is required to determine
the health status of the population.

Total refugee or displaced population

Age-sex breakdown

Identification of at-risk groups; e.g., children less than

5 years of age, pregnant and lactating women, disabled and wounded
persons, and unaccompanied minors

Average family or household size

Why this information is needed. The total population will be used
as the denominator for all birth, death, injury, morbidity, and
malnutrition rates to be estimated later. The total population is
necessary for the calculation of quantities of relief supplies. The
breakdown of the population by age and sex allows for the
calculation of age- and sex-specific rates and enables
interventions to be targeted effectively (e.g., immunization
campaigns).

Sources of information. Local government officials or camp
authorities may be able to provide registration records. If no
registration system is in effect, one should be established
immediately. Information recorded should include the names of
household heads, the number of family members by age and sex,
former village and region of residence, and ethnic group, if
applicable.

Refugee leaders may also have records, particularly if entire
villages have fled together. In certain situations, political
groups may have organized the exodus and may have detailed lists of
refugee families.

A visual inspection of the settlement may provide a general
impression of the demographic composition of the population.
However, information obtained in this manner should be used
judiciously as it is likely to provide a distorted view of the
situation.

It may be necessary to conduct a limited survey on a
convenience sample in order to obtain demographic information.
Beginning at a randomly selected point, survey a sample (e.g., 50)
of dwellings. Visit every fifth or 10th house until the
predetermined number of houses have been surveyed. At each house,
record the number of family members, the age and sex of each
person, and the number of pregnant or lactating women. This process
will establish an initial estimate of the demographic composition
of the population. Estimate the number of persons in each house, as
well as the total number of houses in the settlement, to gain a
provisional estimate of the camp population. At the very least,
this quick survey should give a rough estimate of the proportion of
the total population made up of "vulnerable" groups; i.e., children
less than 5 years of age and women of child bearing age. To
determine the total population, a census may need to be conducted
later.

Background health information

The information required includes:

Main health problems in country of origin.

Previous sources of health care (e.g., traditional
healers).

Important health beliefs and traditions (e.g., food taboos

during pregnancy).

Social structure (e.g., whether the refugees are grouped in

their traditional villages and what type of social or political
organization exists).

Strength and coverage of public health programs in country

of origin (e.g., immunization).
Why this information is needed. Effective planning of health
services will depend on this information. Planners need to be aware
of traditional beliefs, taboos, and practices in order to avoid
making costly mistakes and alienating the population.
Sources of information. Obtain documents and reports from the host
government, international organizations, and nongovernment
organizations pertaining to endemic diseases and public health
programs in the displaced population's region of origin.

Seek information from development agencies, private companies,
missionaries, or other groups having experience with the displaced
population.

Nutritional status

The information required includes:

Prevalence of protein-energy undernutrition in the

population less than 5 years of age.

Nutritional status before arrival in host country.

Prevalence of micronutrient deficiencies in the population

less than 5 years of age.

Why this information is needed. Evidence exists to support the
fact that the nutritional status of displaced populations is
closely linked with their chances of survival. Initial assessment
of nutritional status serves to establish the degree of urgency in
delivering food rations, the need for immediate supplementary
feeding programs (SFPs), and the presence of micronutrient
deficiencies that require urgent attention.

Sources of nutritional information. If refugees are still arriving
at the site:

Initiate nutritional screening of new arrivals immediately.

Measure all children (or every third or fourth child, if

insufficient trained personnel are available or the refugee influx
is too great) for mid-upper arm circumference (MUAC) or, if time
and personnel permit, WFH. Estimate the proportion of
undernourished children using the methods described in the Rapid
Nutrition Assessment Manual. *

screening program for new arrivals. A screening program also can be
used to administer measles vaccination and vitamin A supplements to
new arrivals.

If refugees are already located in a settlement:

Walk through the settlement, select houses randomly, and

observe the nutritional status of the children less than 5 years
of age. Visual assessment should only be done by persons who are
experienced in the assessment of malnutrition. The observer should
enter the homes as malnourished children are likely to be
bedridden.

Combine the visual inspection with a rapid assessment of

nutritional status, using either MUAC or WFH measurements. This can
be done during the demographic survey described above. (See "Rapid
Health Assessment")

Review the records of local hospitals treating members of

the displaced population. Note admissions or consultations for
undernutrition and deaths related to undernutrition.

Interview refugee leaders to establish food availability

before displacement and the duration of the journey from place of
origin to their present location.

In order to gather baseline data for evaluation of nutrition
programs, plan to conduct a valid, cluster sample survey of the
population as soon as possible (within 2 weeks). Appropriate
technical expertise will be needed for the implementation and
analysis of the survey.

Why this information is needed. In the initial stages of a
population displacement, mortality rates, expressed as
deaths/10,000/day, are a critical indicator of improving or
deteriorating health status.

In many African countries, the daily CMR (extrapolated from
published annual rates) is approximately 0.5/10,000/day during
non-emergency conditions. In general, health workers should be
extremely concerned when CMRs in a displaced population exceed
1/10,000/day, or when less than 5 years of age mortality rates
exceed 4/10,000/day.
Sources of mortality information. Check local hospital records and
the records of local burial contractors. Interview community
leaders.

Establish a mortality surveillance system. One approach is to
designate a single burial site for the camp, which should be
monitored by 24-hour grave watchers. Grave watchers should be
trained to interview families, using a standard questionnaire, and
then to record the data to determine gender, approximate age, and
probable cause of death.

Other methods of collecting mortality data include registering
deaths, issuing burial shrouds to families of the deceased to
ensure compliance, or employing volunteer community informants who
report deaths for a defined section of the population.

Demographic data are absolutely essential for calculating
mortality rates. These provide the denominator for estimating death
rates in the entire population and within specific vulnerable
groups, such as children less than 5 years of age.

The population needs to be assured that death registration
will have no adverse consequences (e.g., ration reductions).
Morbidity

The information required includes age- and sex-specific data
regarding the incidence of common diseases of public health
importance, i.e., measles, malaria, diarrheal diseases, and ARI, as
well as diseases of epidemic potential such as hepatitis and
meningitis. The data should be collected by all health facilities,
including feeding centers.
Why this information is needed. Data on diseases of public health
importance may help plan an effective preventive and curative
health program for refugees. These data will also facilitate the
procurement of appropriate medical supplies and the recruitment and
training of appropriate medical personnel, as well as focus
environmental sanitation efforts (e.g., toward mosquito control in
areas of high malaria prevalence).
Sources of morbidity information. Review the records of local
clinics and hospitals to which refugees have access.

Where a clinic, hospital, or feeding center has already been
established within the camp, examine patient records or registers
and tally common causes of morbidity. Interview refugee leaders and
health workers within the refugee population.

A simple morbidity surveillance system should be established
as soon as curative services are established in the camp. Feeding
centers should be included in the surveillance system. Community
health workers should be trained as soon as possible to report
diseases at the community level.

The initiation of certain public health actions should not be
delayed until the disease appears. For example, measles
immunization should be implemented immediately. Do not wait for the
appearance of measles in the camp. Also, oral rehydration centers
should be routinely established in all situations.

Environmental conditions

The information required includes:

Climatic conditions (average temperatures and rainfall

patterns).

Geographic features (soil, slope, and drainage).

Water sources (local wells, reservoirs, rivers, tanks).

Local disease epidemiology (endemic infectious diseases,

e.g., malaria, schistosomiasis).

Local disease vectors (mosquitoes, flies, ticks), including

breeding sites.

Availability of local materials for shelter and fuel.

Existing shelters.

Existing sanitation arrangements (latrines and open areas).

Why this information is needed. Information on local environmental
conditions affecting the health of displaced populations will help
relief planners create priorities for public health programs.
Sources of information. This assessment is made largely by visual
inspection. In addition, interviews with local government and
technical specialists will yield important information. In some
cases, special surveys need to be conducted; e.g., entomologists
may need to survey for local disease vectors, and water engineers
may need to assess water sources.

Resources available
Food supplies

Efforts to evaluate food supplies should include:

Attempting to assess the quantity and type of food
currently

available to the population.

Calculating the average per capita caloric intake over the

period of time for which records are available, if food is already
being officially distributed.

Inspecting any local markets for food availability and

prices.

Conducting a quick survey of dwellings and estimating the

average food stores in each household. This should be done during
the demographic survey (see "Rapid Health Assessment"). Look for
obvious inequities between different families or different ethnic
or regional groups.

Food sources. Local, regional, and national markets need to be
assessed. The cash and material resources of the displaced
population should also be assessed in order to estimate its local
purchasing power.

center), as well as the size, capacity, and structure (tent, local
materials).

Determine the adequacy of health-facility water supply.

Assess refrigeration facilities, fuel, and generator.

Assess supplies of essential drugs (whether generic or

brandname) and medical supplies.

Determine the need for essential vaccines and immunization

equipment.

Note the type of health personnel (doctors, nurses,

nutritionists, sanitarians) and their relevant experience and
skills.

Review storage facilities.

Assess adequacy of transport, fuel, and communications.

Locate health workers in refugee population (traditional

healers, birth attendants, "modern" practitioners).

Determine whether there is a need for interpreters.

Taking action

An itemized summary of the findings should be prepared,

following the sequence of activities outlined in this document.

Estimate and quantify the need for outside assistance,
based

on preliminary findings.

Prepare and convey assessment findings to appropriate

emergency health officials at the local, national, and
international levels.

Checklist For Rapid Health Assessment *

Adapted from : WHO Emergency Relief Operations. Emergency
Preparedness and Response: Rapid Health Assessment in Sudden
Population Displacements. WHO, in collaboration with CDC and other
WHO Collaborating Centers for Emergency Preparedness and Response.
Geneva: January 1990.

Preparation

Obtain available information regarding refugees and

resources from host country ministries and organizations.

Obtain available maps or aerial photographs.

Obtain demographic and health data from international

organizations.

Field assessment

Determine total displaced population.

Determine age and sex breakdown of population.

Identify groups at increased risk.

Determine average household size.

Health information

Identify primary health problems in country of origin.

Identify previous sources of health care.

Ascertain important health beliefs and traditions.

Determine the existing social structure.

Determine the strength and coverage of public health

programs in country of origin.

Nutritional status

Determine prevalence of PEM in population less than 5
years

of age.

Ascertain prior nutritional status.

Determine prevalence of micronutrient deficiencies in the

population less than 5 years of age.

Mortality rates

Calculate crude, age-, sex-, and cause-specific mortality

rates.

Morbidity

Determine age- and sex-specific incidence rates of diseases

that have public health importance.

Environmental conditions

Determine climatic conditions.

Identify geographic features.

Identify water sources.

Ascertain local disease epidemiology.

Identify local disease vectors.

Assess availability of local materials for shelter and
fuel.

Assess existing shelters and sanitation arrangements.

Resources available

Assess food supplies and distribution systems.

Identify and assess local, regional, and national food

sources.

Assess the logistics of food transport and storage.

Assess feeding programs.

Identify and assess local health services.

Assess camp health services.

Health Information System

A health information system (HIS) provides continuous
information on the health status of the refugee community and
comprises both ongoing routine surveillance and intermittent
population-based sample surveys. This information may be used to:

Follow trends in the health status of the community and

establish health-care priorities.

Detect and respond to epidemics.

Evaluate program effectiveness and service coverage.

Ensure that resources are targeted to the areas of greatest

need.

Evaluate the quality of care delivered.

Data collection

As soon as health services are established for a refugee
population, a surveillance system should be instituted and should
ideally be set up at the time of an initial, rapid assessment. Any
agency or facility (including feeding centers) providing health
services to the refugee population should be part of the reporting
network. Any host community services to which the refugees might
have access should also be part of the system.

Health information should be reported on a simple,
standardized surveillance form. (A sample form, adapted from WHO
Emergency Relief Operations, is located at the end of this
section.) Each health facility should be held accountable for
completing the reporting form at the appropriate interval and for
returning it to the person or agency charged with compiling the
reports, analyzing the information, and providing feedback. Each
refugee settlement or camp should have a person responsible for
coordinating the HIS. Forms should be translated into the
appropriate local language(s) if community health workers are
involved in information collection.

Health facilities should keep a daily record of patients; age,
sex, clinical and laboratory diagnosis, and treatment should be
specified. If personnel time is limited, a simple tally sheet
should be used. In addition, the patient should be issued a health
record card on which the date, diagnosis, and treatment are
recorded. Each time a patient contacts the health-care system,
whether for curative or preventive services, this should be noted
on the health record card. Laboratory data should accompany
diagnostic information whenever possible. Collecting Processing,
Storing, and Shipping Diagnostic Specimens in Refugee Health-Care
Environments * provides an overview of procedures for collecting
and
processing diagnostic specimens in the field.

Data collection should be limited to that information that can
and will be acted upon. Information that is not immediately useful
should not be collected during the emergency phase of a refugee
relief operation. Overly detailed or complex reporting requirements
will result in noncompliance.

The most valuable data are generally simple to collect and to
analyze. Standard case definitions for the most common causes of
morbidity and mortality should be developed and put in writing. The
data collected will fall into one of the following categories: a)
demographic, b) mortality, c) morbidity, d) nutritional status, and
e) health program activities.
Population. Camp registration records should provide most of the
demographic information needed. If registration records are
inadequate, a population census may be necessary. Conducting a
census is often politically sensitive and may be delayed by the
administrative authorities for a long period of time. Consequently,
innovative methods may need to be devised. For example, organize a
nutritional screening of all children less than 5 years of age.
Count the children and estimate the percentage of the total
population less than 5 years of age by doing a sample survey. From
this information, estimate the total population size. For other
methods to determine population size and structure see "Rapid
Health Assessment".

It is important that population figures be updated on a
regular basis, taking into account new arrivals, departures,
births, and deaths. The total population is used as the denominator
in the calculation of disease incidence, birth, and death rates.
This total is also necessary to determine requirements for food and
medical supplies and to estimate program coverage rates.
Information about the population structure is needed to calculate
age- and sex-specific morbidity and mortality rates, to estimate
ration requirements, and to determine the target population for
specific interventions, i.e., antenatal care and immunizations.

The rate of new arrivals and departures gives an indication of
the stability of the population and will influence policy decisions
about long-term interventions, such as TB therapy. This information
is also used to predict future resource and program needs.

A birth registration system is usually simple, since the
community expects an increase in the family food ration as a result
of a new birth. Births might be reported in the community to
volunteer health workers or traditional birth attendants.
Alternatively, if good antenatal care services are established,
follow-up of pregnant mothers will allow for a relatively complete
registration of births. Examples of mortality surveillance systems
are described in "Rapid Health Assessment". Deaths may be
underreported if there is a fear of possible ration reduction;
thus, an agreement might be negotiated with camp authorities not to
decrease rations after a death occurs -- at least during the
emergency phase. Arrivals and departures should be monitored
through the camp registration system.

Mortality. Each health facility should keep a log of all patient
deaths (with cause of death and relevant demographic information)
and report the deaths on a standardized form. Because many deaths
occur outside of the health-care system, a community-based
mortality surveillance system should be established. Such a system
may include the employment of grave watchers, the routine issuance
of burial shrouds, and the use of community informants (see "Rapid
Health Assessment").

Death rates are the most specific indicators of a population's
health status and are the category of data to which donors and
relief agencies most readily respond. During the emergency phase of
a relief operation, death rates should be expressed as
deaths/10,000/day to allow for detection of sudden changes. In
refugee camps, relief programs should aim at achieving a CMR of
less than 1/10,000/day as soon as possible. This rate still
represents approximately twice the "normal" CMR for non-displaced
populations in most developing nations and should not signal a
relaxation of efforts. After the emergency phase, death rates
should be expressed as deaths/1,000/month to reflect the usual
reporting frequency and to facilitate comparison with baseline,
non-refugee death rates.

Age- and sex-specific mortality rates will indicate the need
for interventions targeted at specific vulnerable groups. During
the early stage of a relief operation, specific death rates for
persons less than 5 years of age and greater than 5 years of age
may suffice. Later, further disaggregation by age may be feasible
--
for example, less than 1 year, 1-4 years, 5-14 years, and greater
than 15 years. Different male- and female-specific death rates may
reflect inequitable access to resources or health services.
Cause-specific mortality rates will reflect those health problems
having the greatest impact on the refugee community and requiring
the highest priority in public health program planning.

Morbidity. Health facilities and feeding centers should report
morbidity information on the same form on which mortality is
reported. Each disease reported in the system must have a written
case definition that will guide health workers in their diagnosis
and ensure the validity of data. Where practical, case definitions
that rely on clinical signs and symptoms should be tested
periodically for sensitivity and specificity as compared with a
laboratory standard (e.g., malaria).

Knowledge of the major causes of illness and the groups in the
affected population that are at greatest risk allows for the
efficient planning of intervention strategies and the most
effective use of resources. Morbidity rates are more useful than a
simple tallying of cases, as trends can be followed over time, or
rates compared with those from different populations. The
monitoring of proportional morbidity (e.g., percentage of all
morbidity caused by specific diseases) may be useful when specific
control measures are being evaluated, although caution is needed in
the interpretation of trends. A relative decrease in
disease-specific proportional morbidity may merely reflect an
absolute increase in the incidence of another disease.
Nutritional status. Data regarding nutritional status can be
obtained through a nutritional assessment survey or a mass
screening exercise. Surveys should be repeated at regular intervals
to determine changes in nutritional status; however, not so
frequently as to obscure true differences between surveys. All
children less than 5 years of age should undergo a nutritional
screening upon arrival at the camp and should continue to be
weighed and measured monthly at MCH clinics in the camp.
Information collected during these screenings should be included in
HIS reports. If the initial screening identifies high prevalence
rates of undernutrition, cross-sectional surveys should be repeated
at intervals of 6-8 weeks until the undernutrition prevalence rate
is below 10%. Thereafter, surveys every 6-12 months will suffice,
unless routine surveillance data indicate that nutritional status
has deteriorated. Measurement of nutritional status is described in
the Rapid Nutrition Assessment Manual. *

The prevalence of acute malnutrition acts as an indicator of
the adequacy of the relief ration. A high prevalence of
malnutrition in the presence of an adequate average daily ration
may indicate inequities in the food distribution system, or high
incidence rates of communicable diseases (e.g., measles and
diarrhea). The presence of nutritional deficiency disorders (i.e.,
pellagra, anemia, or xerophthalmia) indicates the need for ration
supplementation.

Programs. Each health facility should keep a log of all
activities. Immunizations should be recorded in a central record,
as well as on the person's health record card. Records of health
sector activities will be useful in determining whether certain
groups in the population are underserved, and in planning measures
to reach a broader population base. Although approximate
immunization coverage may be estimated from the number of vaccine
doses administered, the preferred method is by annual population
surveys.

Analysis and interpretation

Most data can be analyzed locally using a pen and paper. The
use of computers and a data entry and analysis program, such as Epi
Info, version 5, may be practical at the regional or national
level. Trends in mortality, morbidity, and nutritional status
should be monitored closely. Careful attention should be paid to
changing denominators, and changes in proportional mortality or
morbidity should be interpreted with particular caution. Where
applicable, correlations between mortality, morbidity or
nutritional status, and health sector activities should be
examined. Likewise, the proportion of malnourished children
identified in population surveys as enrolled in feeding programs
can be used to estimate program coverage. All components of the HIS
should be analyzed and interpreted in an integrated fashion. A
single element examined alone will reveal only a small portion of
the entire picture and may be easily misinterpreted. For example,
an apparent decrease in malnutrition prevalence should be
interpreted in the context of childhood mortality rates (1). The
use of health information to guide program decision-making will be
facilitated if targets and critical indicators are established at
the beginning. For example, a measles incidence rate of
1/1,000/month might be an indicator that would initiate specific
preventive actions. Similarly, during a cholera outbreak, a CFR of
3% in a given week might stimulate a critical review of case
management procedures.

Control measures

The information gathered through the HIS should be used to
develop recommendations and to implement specific control measures.
Objectives for disease control programs should be established and
progress towards these objectives regularly assessed. The
presentation of data to decision-makers should make use of simple,
clear tables and graphs. Most importantly, there should be regular
feedback to the data providers through newsletters, bulletins, and
frequent supervisory visits.

Assessment

The HIS should be periodically assessed to determine its
accuracy, completeness, simplicity, flexibility, and timeliness.
The utilization of the data by program planners and key
decision-makers should also be assessed. The HIS should evolve as
the need for information changes.

For populations totally dependent upon food aid, a general
ration of at least 1,900 kcal/person/day is required. At least 10%
of the calories in the general ration should be in the form of fats
and at least 12% should be derived from proteins.

Each of the rations above provides at least minimum

quantities of energy, protein, and fat.

Ration 2 provides additional quantities of various

micronutrients through the inclusion of a fortified blended cereal.
When provided in the general ration, fortified cereal blends should
be used for the whole family.

The calculation of rations should account for calorie loss
during transport and food preparation. Similarly, when the mean
daily temperature falls below 20 C, the caloric requirement should
be increased accordingly by 1% per degree of temperature below 20
C.

The standard requirement of 1,900 kcals is based on the
following demographic structure of a population:

Children less than 5 years of age (20%).

Children 5-14 years of age (35%).

Women 15-44 years of age (20%), of whom 40% are pregnant or

lactating.

Males 15-44 years of age (10%).

Adults greater than 44 years of age (15%).
The calculation of ration requirements should be adjusted for

deviations from the above population structure (age/gender
breakdown), the underlying health and nutritional status of the
population, and relative activity levels of the community.

Guidelines for ration distribution

Food should be distributed in a community setting. Camps
and

mass feedings should be avoided if at all possible.

Ration distribution should complement, not replace, any
food

that the refugees are able to provide for themselves.

Distributed food should be familiar and culturally

acceptable to the refugees.

If food is distributed in uncooked form, adequate fuel and

cooking utensils should be made available.

Grains should be provided in ground form, or grinders must

be made available.

Distribution must be done on a regular basis, with no
longer

period than 10-14 days between distributions.

If a specified food item in the ration cannot be supplied,

the energy and nutrient content of the missing item should be
provided by including additional quantities of another available
commodity. This type of substitution is appropriate only as a
short-term measure.

Breast-feeding should be encouraged and supported.

Lactating women should be provided with extra sources of

calories and protein. Appropriate weaning foods should be included
in the general ration (fats and oils).

Bottle feeding should be discouraged. Infant bottles and

formula should not be distributed.

Dry skim milk (DSM) and other milk products should not be

included in the ration as such, except where milk consumption is
part of the traditional diet. Milk products should be mixed with
milled grains to form a cereal. Any milk product that is included
in the rations should be fortified with vitamin A.

If fresh fruits and vegetables are not available, fortified

blended foods (e.g., corn-soya milk (CSM)), CSB, or similar local
products) should be provided to meet micronutrient requirements.

Refugees should be encouraged to grow vegetables. Seeds,

gardening implements, and suitable land should be made available
for kitchen gardens. This is critical for the prevention of
pellagra and scurvy.

Refugees should be permitted access to local markets and be

allowed to create markets. Trading or selling of ration commodities
may be a necessary part of the camp economy. It enables refugees to
supplement their diets with foods otherwise unavailable to them and
to obtain essential nonfood items.

It may be advisable to include certain culturally

significant items i.e., tea, sugar, and spices in the food basket.
Where such items are highly valued, refugees will sell or trade
part of their ration to obtain them. This results in a reduction of
caloric intake. Providing these items eliminates this overall
reduction.

Supplementary feeding programs

SFPs are designed to help prevent severe malnutrition and to
rehabilitate moderately malnourished persons. SFPs are not intended
to be used as a method of targeting food during an emergency phase.
Similarly, SFPs are inappropriate as a long-term supplement to an
inadequate general ration.

Implementation of a SFP is necessary under the following
circumstances:

When the general ration is less than 1,500 kcal/person.

Where nutritional assessment reveals that greater than 20%

of children less than 5 years of age are acutely malnourished, as
determined by a Z-score indicator of less than -2.

When the acute malnutrition prevalence (as determined by a

Z-score indicator of less than -2) falls between 10%-20% and the
general ration is between 1,500-1,900 kcal.

Where there is a high incidence of measles or diarrheal

disease.

Inclusion and discharge criteria.

The following groups should be targeted for inclusion in a
SFP:

Acutely undernourished children less than 5 years of age

(WFH Z-score less than -2 or less than 80% of reference median).

Pregnant and lactating women.

Elderly, chronically ill (e.g., TB patients), or

disadvantaged groups.

Children should be discharged from the SFP after they have
maintained greater than 85% of median WFH (or a Z-score greater
than -1.5) for a period of 1 month.
Caloric requirements. A SFP should provide at least 500 kcal and
15 g protein/day in one or two feedings.

High energy milk (HEM), a calorie-dense milk mixture, may be
used in a SFP. One milliliter of HEM provides 1 kcal of energy. The
formula below makes 5 L of HEM:

420 g dried skimmed milk,
250 g sugar,
320 g oil, and
4.4 L water
If the general ration is inadequate (less than 1,900
kcal/person/day), the supplementary ration should provide 700-1,000
kcal/person/day in two to three feedings.
Types of SFPs. SFPs fall into two categories, either on-site
feeding or take-home rations. Listed below are some of the
advantages and disadvantages of each type of SFP (1).

On-site feeding. "Wet" rations are prepared by SFP staff and
served to recipients in the feeding center. Listed below are the
advantages of wet rations:

The likelihood that the ration will be shared among family

members is reduced.

SFP staff maintain control over the preparation and

consumption of the supplementary meals.

Additional services can be incorporated into the feeding

program.

These are the disadvantages of wet rations:

Young children must be accompanied to the center. This may

lead to poor attendance rates and create a hardship for many
mothers who must also provide for other family members.

Feeding centers must be located near the homes of the

recipients.

In order to increase motivation and attendance, other

services may need to be offered.

Feeding centers are a drain on health personnel resources.

Feeding center meals may be substituted for meals at home,

resulting in a net food intake deficit.

On-site feedings are not appropriate for targeting entire

families or community groups.

Children less than 2 years of age are generally underserved

by on-site feedings.

On-site feedings remove the family's responsibility and

control over providing for family members.

The possibility of cross-contamination and infection is

increased in mass feedings.

Take-home programs. "Dry" rations are provided on a regular basis
to supplement the general ration normally received. These are the
advantages of dry rations:

Daily attendance of the enrollee or other family members is

not required.

Fewer centers are needed, and these may be located at a

greater distance from homes.

The supplementary ration increases the purchasing power of

the family.

The ration is intended to provide supplementation 365

days/year. (No missed days for holidays)

Dry rations generally achieve higher coverage rates than
wet

rations.

There is less disruption of family activities, as daily

attendance is not required.

The family is able to maintain control over feeding

practices.

These are the disadvantages of dry rations:

Dry rations are less effective at targeting person

beneficiaries.

Sharing of the ration among family members is increased.

Other elements of SFPs

Vitamin A should be administered upon admission to the SFP

and every 3 months thereafter.

If vitamin C is not included from the ration, vitamin C

supplements should be administered weekly to all persons enrolled
in SFPs.

If iron deficiency anemia is highly prevalent, the
provision

of iron syrup to children enrolled in SFPs should be considered.

All enrollees in the SFP should have their measles

immunization status checked upon admission, and vaccine
administered if needed.

Mebendazole, an anthelminthic, should be administered along

with the vitamin A, if it is available. Each child should be
administered two 100 mg tablets to be chewed. Mebendazole should
not be administered to infants less than 12 months of age or to
pregnant women.

On-site feeding centers require a regular supply of clean

water and cooking fuel.

Therapeutic feeding programs

Therapeutic feeding programs (TFPs) are considered a medical
intervention, the purpose of which is to save lives and restore the
nutritional health of severely malnourished children. The
recommendations listed below are adapted from the procedures for
selective feeding (2).

Enrollment criteria. Children should be enrolled in a TFP if they
meet one of the following criteria:

Children less than 5 years of age (or less than 115 cm in

height) with WFH Z-score of less than -3 (less than 70% median).

Children with clinically evident edema.

Children referred to TFP by medical personnel.

Caloric requirements

Children enrolled in a TFP should receive 150 kcal and 3 g

of protein for each kg body weight/day.

Feeding should be done in four to six meals/day. Feeding

centers that provide meals on a 24-hour basis are likely to be most
effective.

HEM should be included in the TFP ration.

All children enrolled in the TFP should receive a full

course of vitamin A upon admission.

Severely malnourished children typically have poor
appetites

and may require nasogastric feedings for short intervals. Trained
and experienced personnel are needed for this procedure.

Discharge criteria. Discharge from a TFP to a SFP should occur
when the following criteria are met:

The child has maintained 80% WFH (or a Z-score of -2) for a

period of 2 weeks.

Weight gain has occurred without edema.

The child is active and free from obvious illness.

The child exhibits a good appetite.

Monitoring requirements

A register should be maintained with the details of each

patient.

Each patient should be given a personal ration card and an

identification bracelet.

Each patient should be weighed daily at first, and then

twice weekly to monitor progress.

TFPs should aim for a weight gain of 10 g/kg body

weight/day.

All absentees should be followed up at home and encouraged

to resume attendance.

Regular nutrition surveys should be conducted, and

malnourished children who are not enrolled in a feeding program
should be referred to either the SFP or the TFP. Feeding programs
should aim for at least 80% enrollment and 80% daily attendance. In
addition, health workers should be involved in active case-finding
in the community.

Provision of micronutrients

Ideally, the recommended daily allowances for all essential
nutrients should be provided in the general rations. However,
specific measures may be necessary to provide certain
micronutrients.

Vitamin A
Risk factors for vitamin A deficiency. Provide vitamin A
supplements whenever any of the following conditions are present:

The refugee population originates from a geographic area at

high risk for vitamin A deficiency.

There is evidence of severe vitamin A deficiency in the

population.

The general ration provides inadequate quantities of
vitamin

A (less than 2,000-2,500 IU/person/day).
Supplemental doses and schedule

Children 12 months 5 years of age should receive 200,000 IU

every 3 months.

Infants less than 12 months of age should receive 400,000
IU

total dose in the first year of life, administered as follows:

If a dose can be assured every 3 months: 100,000 IU to the

infant every 3 months for 1 year.

If 3-month dosing is impractical but 6-month dosing is

anticipated: 200,000 IU to the infant every 6 months for 1 year.

If any subsequent dosing is unlikely: 200,000 IU to the

infant when examined.

In all cases, mothers should be administered 200,000 IU within
2 months of giving birth in order to provide adequate quantities of
vitamin A in the breast milk. If it is not possible to provide
supplements to the mother at or within 2 months of giving birth,
then the mother should receive 100,000 IU during the third
trimester of pregnancy.

If xerophthalmia is observed in older children and adults,

include the affected age groups in the standard 200,000 IU
preventive vitamin A supplementation program administered to
younger children.

As a general practice, all doses of vitamin A should be

documented on the child's growth record chart.

Full treatment schedule. A full treatment schedule of oral vitamin
A should be administered to all persons suffering from severe
malnutrition (WFH Z-score less than -3) or exhibiting eye symptoms
of vitamin A deficiency (xerosis, Bitot's spots, keratomalacia, or
corneal ulceration). The dose schedule is given below:

200,000 IU on day 1,
200,000 IU on day 2, and
200,000 IU 1 to 4 weeks later.
Children less than 12 months of age receive half doses.
Anemia. The prevalence of anemia can be determined through a rapid
anemia survey using a portable Hb photometer (HemoCue system).

The CDC has established the following criteria for defining
anemia:

Children 15 years of age: Hb less than 11.0 g/dL

Pregnant women: Hb less than 11.0 g/dL

Nonpregnant women: Hb less than 12 g/dL

Men: Hb less than 13.5 g/dL
The risk of anemia is highest in pregnant and lactating women,

and in children ages 9-36 months. If the general ration contains
inadequate amounts of absorbable iron, folate, and vitamin C,
anemia may be prevented through the daily administration of
iron/folate tablets and vitamin C supplements. Supplementary
feeding of high-risk groups with CSM will also help to reduce the
likelihood of anemia (CSM contains 18 g iron/100 g).

Iron/folic acid. Routine iron/folate supplements should be
provided to all pregnant and lactating women through antenatal and
postnatal clinics. Female health workers should be employed to seek
out pregnant and lactating women and encourage their participation
in these programs.

Vitamin C. Fortification of foods with vitamin C is problematic
because vitamin C is unstable. Further study is needed on the
appropriate vehicle for fortification. The best solution is to
provide a variety of fresh foods either by including them in the
general ration or by promoting access to local markets. In
addition, local cultivation of vitamin C-containing foods should be
encouraged. Patients with clinical scurvy should be treated with
250 mg of oral vitamin C two times daily for 3 weeks.

Niacin. Maize-eating populations are at greatest risk for niacin
deficiency, which causes pellagra. Recent studies of pellagra
outbreaks among refugee populations found groundnut consumption,
garden ownership, and home maize milling (as an indicator of higher
socioeconomic status) to be protective factors. Niacin-fortified
flour should be included in the general ration. The process of
fortifying maize flour with niacin is simple and relatively
inexpensive.

Clinical cases of pellagra can be treated with nicotinamide.
The recommended treatment schedule is 100 mg three times daily for
3 weeks. The total daily dose of nicotinamide should not exceed 600
mg. Where the diet is deficient in niacin, vitamin B complex
tablets can be used to prevent pellagra.

Iodine. If the general ration is naturally deficient of iodine,
fortification of items such as salt or monosodium glutamate should
be considered.

United Nations Administrative Committee for Coordination,
Subcommittee on Nutrition, and the International Nutrition Planners
Forum. Nutrition in times of disaster. Presented as a report of an
International Conference; September 27-30, 1988; Geneva,
Switzerland.

Only measles immunization should be part of the initial
emergency relief effort; however, a complete EPI should be planned
as an integral part of an ongoing long-term health program.

Diphtheria, tetanus toxoids (TT) and pertussis vaccine (DTP),
oral polio vaccine (OPV), and bacille Calmette-Guerin (BCG)
vaccinations are recommended. None should not be undertaken,
however, unless the following criteria are met: the population is
expected to remain stable for at least 3 months; the operational
capacity to administer vaccine is adequate, and the program can be
integrated into the national immunization program within a
reasonable length of time.

It is essential that adequate immunization records be kept. At
the very minimum, personal immunization cards (i.e., "Road to
Health" cards) should be issued. In addition, a central register of
all immunizations is desirable.

Measles
Priority. Measles vaccination campaigns should be assigned the
highest priority early in emergency situations. Measles
immunization programs should begin as soon as the necessary
personnel, vaccine, cold chain equipment, and other supplies are
available. Measles immunization should not be delayed until other
vaccines become available or until cases of measles have been
reported.

In refugee populations fleeing from countries with high
immunization coverage rates, measles immunization should still be
accorded high priority. Studies of urban populations (e.g.,
Kinshasa, Zaire) and densely populated refugee camps (e.g., camps
in Malawi) have shown that large outbreaks of measles may still
occur even if vaccine coverage rates exceed 80%. For example, in a
camp of 50,000 refugees, approximately 10,000 would be children
less than 5 years of age. If the vaccine coverage rate was 80% and
vaccine efficacy was 90%, approximately 2,800 children in this camp
would still be susceptible to measles. In addition, certain
countries achieved high coverage in the 12 to 23 month age group,
leaving large numbers of older children unprotected.

Program management. Responsibilities for each aspect of the
immunization program need to be explicitly assigned to agencies and
persons by the coordination agency.

The national EPI should be involved from the outset of the
emergency. National guidelines regarding immunization should be
applied in refugee settings.

A pre-immunization count should be conducted to estimate the
number of children eligible for vaccination. This should not be
allowed, however, to delay the start of the vaccination program.
Choice of vaccine. The standard Schwarz vaccine is recommended.
The use of medium or high titer Edmonston-Zagreb (E-Z) vaccine is
not yet recommended for refugee populations, since there are still
concerns about its safety.
Target population. During the emergency phase, defined as that
time during which the CMR is higher than 1/10,000/day, all children
ages 6 months-5 years should be vaccinated upon arrival at the
camp.

In long-term refugee health programs, vaccination should be
targeted at all children ages 9 months-5 years, except during
outbreaks when the lower age limit should again be dropped to 6
months.

Any child who has been vaccinated between the ages of 6 and 9
months should be revaccinated as soon as possible after reaching 9
months of age, or 1 month later if the child was 8 months old at
first vaccination.

If there is insufficient vaccine available to immunize all
susceptible children, the immunization program should be targeted
at the following high-risk groups, in order of priority:

Undernourished or sick children ages 6 months-12 years who

are enrolled in feeding centers or inpatient wards.

All other children ages 6-23 months.

All other children ages 24-59 months.
Older children, adolescents, and adults may also need to be

immunized if surveillance data show that these groups are being
affected during an outbreak.

Undernutrition is not a contraindication for measles
vaccination! Undernutrition should be considered a strong
indication for vaccination. Similarly, fever, respiratory tract
infection, and diarrhea are not contraindications for measles
vaccination. Unimmunized persons who are infected with HIV should
receive the vaccine. Measles vaccine should also be administered in
the presence of active TB (1).

Outbreak control. Measles immunization programs should not be
stopped or postponed because of the presence of measles in the camp
or settlement. On the contrary, immunization efforts should be
accelerated.

Among persons who have already been exposed to the measles
virus, measles vaccine may provide some protection or modify the
clinical severity of the disease, if administered within 3 days of
exposure.

Isolation of patients with measles is not indicated in an
emergency camp setting.

Case management. All children who develop clinical measles in
refugee camps should have their nutritional status monitored and be
enrolled in a feeding program if indicated.

Children with measles complications should be administered
standard treatment, e.g., ORT for diarrhea and antibiotics for
acute lower respiratory infection (ALRI).

If they have not received vitamin A during the previous month,
all children with clinical measles should receive 200,000 IU
vitamin A orally. Children less than 12 months of age should
receive 100,000 IU. This should be repeated every 3 months as part
of the routine vitamin A supplementation schedule.

Children with complicated measles (pneumonia, otitis, croup,
diarrhea with moderate or severe dehydration, or neurological
problems) should receive a second dose of vitamin A on day 2.

If any eye symptoms of vitamin A deficiency are observed
(xerosis, Bitot's spots, keratomalacia, or corneal ulceration), the
following treatment schedule should be followed:

200,000 IU oral vitamin A on day 1.
200,000 IU oral vitamin A on day 2.
200,000 IU oral vitamin A 1-4 weeks later.
Children less than 12 months of age receive half doses.

Diphtheria-tetanus-pertussis

Once a comprehensive EPI has been established, all children
ages 6 weeks-5 years should receive three doses of DTP, 4-8 weeks
apart.

Poliomyelitis

One dose of OPV should be administered at birth, followed by
three doses 4-8 weeks apart to all children 6 weeks-5 years of age.

Tuberculosis

BCG vaccination should be offered as part of the comprehensive
EPI, rather than as a separate TB program. One dose of BCG is
administered subcutaneously at birth. Recommendations for TB
control are presented in a separate section.

Neonatal tetanus

All women between the ages of 15-44 years should receive a
full schedule of TT vaccination. Vaccination should commence at a
younger age if girls less than 15 years of age commonly bear
children in the refugee community. TT vaccination should be
included as part of a standard antenatal care program. Female
health workers should be employed to educate women about the need
for the TT vaccination and to refer pregnant women to the antenatal
care clinic. Although WHO recommends a 5-dose schedule for TT
vaccination (see "WHO Tetanus Toxoid Vaccination Schedule"), the
number of doses of TT administered varies from country to country.
The schedule in refugee camps should be consistent with host
country national policies.

Meningococcal meningitis
Surveillance. In areas where epidemics of meningococcal meningitis
are known to occur, as in Africa's "meningitis belt," surveillance
for meningitis should be a routine part of a HIS. Such surveillance
requires a standard case definition, the identification (in
advance) of laboratory facilities and a source of supplies (e.g.,
spinal needles, antiseptics, test tubes), and a clearly established
reporting network.

Outbreak identification and control. If an outbreak of
meningococcal meningitis is suspected, early priority should be
given to the determination of etiology and serogroup. This may be
accomplished through the use of latex agglutination tests. It is
also important to determine antibiotic resistance patterns.
Cerebral spinal fluid (CSF) or petechial washings should be placed
in suitable transport media and kept at 37 C during transport to a
local or regional laboratory with the capacity to perform the
needed analysis. If transport media are unavailable, CSF specimens
should be placed in a test tube and transported at body temperature
as soon as possible.

After an outbreak has been confirmed, a presumptive diagnosis
of meningococcal meningitis among persons with suggestive symptoms
and signs can be made by visual inspection of CSF from lumbar
punctures; CSF will appear cloudy in probable cases. Clinical
characteristics include fever, severe headache, neck stiffness,
vomiting, and photophobia.

Endemic rates of meningococcal disease vary by geographic
area, season, and age; thus it is not possible to define a rate
that can be applied universally to identify an epidemic disease. In
one study, an average incidence rate of disease that exceeded 15
cases/100,000/week for a period of 2 consecutive weeks was
predictive of an epidemic (defined as greater than 100
cases/100,000). Since this threshold may only be valid for
populations greater than 100,000 and because the population in a
refugee camp may be unknown, a doubling of the baseline number of
cases from 1 week to the next over a period of 3 weeks may be used
as a rough indicator of a meningitis outbreak.
Vaccination. Vaccination of refugees against meningococcal
meningitis during non-epidemic periods is generally not considered
to be an effective measure because of the short duration of
protection in young children. If there are compelling reasons to
believe that the refugee population is at high risk for an
epidemic, preventive vaccination before the meningitis season may
be warranted.

In the event of an outbreak, vaccination should be considered
if the following criteria are met:

The presence of meningococcal disease is laboratory

confirmed.

Serogrouping indicates the presence of group A or group C

organisms.

The disease is affecting children greater than 1 year of
age

(for group A) or greater than or equal to 2 years (for group C).

If it is logistically feasible, the household contacts of
identified cases should be checked for vaccination status and
immunized if necessary. It may be simpler to organize a mass
immunization program.

Because cases of meningococcal meningitis are likely to
cluster geographically within a refugee camp, it may be most
efficient to focus the vaccination campaign on the affected area(s)
first. Although the target group for immunization should be
determined from the epidemiology of the specific outbreak,
vaccination of children and young adults between the ages of 1-25
years will generally cover the at-risk population.

Hemoprophylaxis. Mass chemoprophylaxis is ineffective for control
of epidemic meningococcal disease and is to be discouraged in a
refugee setting.

If chemoprophylaxis is to be instituted, the following
guidelines should be implemented:

Chemoprophylaxis should be administered simultaneously to

all members of a household where an infected person has been
diagnosed to prevent reinfection. Recovering patients should
receive chemoprophylaxis to eliminate carriage.

Adults: 600 mg rifampicin twice a day for 2 days.

Children greater than 1 month old: 10 mg/kg rifampicin
twice

a day for 2 days.

Neonates: 5 mg/kg rifampicin twice a day for 2 days.
Rifampicin should not be administered to pregnant women.

Patients should be warned that the drug will temporarily turn the
urine and saliva orange.

Ceftriaxone and ciprofloxacin may be used as alternatives to
rifampicin. These drugs, like rifampicin, are expensive and are
generally not considered appropriate in a refugee setting. Because
of widespread resistance, sulfonamides should not be used unless
susceptibility tests show the organism to be sensitive. Widespread
use of rifampicin may encourage drug resistance and could cause
iatrogenic morbidity due to adverse drug reactions.

Treatment. IV-administered penicillin, which requires relatively
intensive nursing care and medical equipment, is the treatment of
choice for meningococcal disease in developed countries. However,
in areas where such intensive care is not possible, a single
intramuscular (IM) dose of long-acting chloramphenicol in oil
suspension (Tifomycin) upon admission has been demonstrated to be
effective. The dosage should be adjusted for age as follows:

greater than or equal to 15 years of age, 3.0 g (6 mL).

11-14 years of age, 2.5 g (5 mL).

7-10 years of age, 2.0 g (4 mL).

3-6 years of age, 1.5 g (3 mL).

1-2 years of age, 1.0 g (2 mL).

less than 1 year old, 50 mg/kg.
In about 25% of cases, a second dose of chloramphenicol will

be needed. Patients should be admitted as inpatients and monitored
closely to determine whether the additional dose is required. The
efficacy of this regimen of one or two doses of IM chloramphenicol
has been proven in studies in both Europe and Africa.

Febrile seizures are common in small children, and
acetaminophen (paracetamol) in either oral suspension or rectal
suppositories should be administered to patients upon admission.

Typhoid and cholera

Vaccination for typhoid or cholera is not recommended in
refugee situations. The resources required for such a campaign are
better spent on improving sanitation conditions (see "Diarrheal
Diseases").

United Nations Children's Fund (UNICEF). Assisting in
emergencies: a resource handbook for UNICEF field staff. New York:
United Nations Children's Fund, 1986:269-77.

Diarrheal Diseases

The critical elements of a diarrheal disease control program
in a refugee camp are: a) prevention of morbidity, b) prevention of
mortality through appropriate case management, c) surveillance for
morbidity and mortality attributed to diarrheal diseases, and d)
preparedness for outbreaks of severe diarrheal diseases (e.g.,
cholera and dysentery). The objectives of a camp diarrheal diseases
control program should include the following:

Maintaining the incidence of diarrheal cases at less than
1%

per month.

Achieving a CFR of less than 1% for diarrheal cases,

including cholera.

Prevention

Efforts aimed at reducing the incidence of diarrheal diseases
and other enterically transmitted diseases should focus primarily
on the provision of adequate quantities of clean water,
improvements in camp sanitation, promotion of breast-feeding, and
personal hygiene education.

The following recommendations relating to water and sanitation
are largely based on the UNHCR Handbook for Emergencies (1) and
Environmental Health Engineering in the Tropics (2).

Water. In general, the supply of adequate quantities of water to
refugees in a camp setting has greater overall impact on health
than a supply of small quantities of microbially pure water. The
provision of adequate quantities of water is particularly effective
in the prevention of bacillary dysentery. Nevertheless, whenever
possible, sources of clean water should be sought or disinfection
systems established. An additional health benefit derived from the
provision of ample supplies of water, at a convenient distance from
the camp, is the decrease in the daily workload of women, upon whom
the burden of water collection usually falls.

Appropriate water sources should be identified before refugees
arrive in an area. An adequate water supply is a crucial component
of attempts to prevent disease and protect health and, as such,
should be among the highest priorities for camp planners and
administrators.

Standards. WHO has set standards for the microbiological quality
of water supplies. These are as follows:

For treated water supplies, the water entering the system

should be free from coliforms. The water at the tap should be free
of coliforms in 95% of samples taken over a 1-year period and
should never have greater than 10 coliforms/100 mL. E. coli should
never be present in the water.

For untreated water supplies, less than 10 coliforms/100
mL

and no evidence of E.coli.

The water quality should be tested before using a water
source, at regular intervals thereafter, and during any outbreak of
diarrheal disease in which the water source may be implicated.
Sources. Whatever water source is chosen, it must be protected
from contamination. Safety measures include:

Springs protected by a spring box.

Wells equipped with a well head, drainage apron, and a

pulley, windlass, or pump.

Surface water, such as lakes, dams, or rivers, provided

there there is a large mass of moving water. If surface water is to
be used, water for drinking should be drawn upstream, away from
obvious sources of contamination.

Rainwater is not generally a practical source in a refugee

setting.

Treatment. The selection of a water source should take into
consideration the potential need for water treatment. Whether or
not treatment is needed, the water should be tested routinely to
ensure that it is of suitable quality.

When surface water is used as a communal source, covered
storage will allow suspended particles to settle on the bottom,
improving the quality of the water. Longer standing times and
higher temperatures will yield a greater improvement in water
quality.

Filtration and chlorination may require considerable effort
and resources, but should be considered if the situation warrants.

Although boiling is an effective means of removing water
pathogens, it is not generally a practical solution in refugee
camps where fuel supplies are limited.

As a short-term measure during an emergency (e.g., a cholera
outbreak, and when treatment of all water sources is not feasible),
purification agents (such as chlorine) may be distributed to each
household. In this way, water can be treated in household storage
containers. However, a massive education effort is required and
such measures usually cannot be maintained for longer than a few
weeks.

Water storage containers with narrow necks or covers that
prevent people from introducing their hands into the container are
likely to reduce further contamination of water once it is stored
in the home. The use of separate containers to store water for
drinking and water for washing is preferable.

Supply. The chosen water supply should be adequate to meet the
needs of the camp year-round. Seasonal variations in rainfall and
in camp population should be taken into consideration when
selecting a water source.

The UNHCR recommends that a minimum quantity of 20 L of
water/person/day be provided. Health clinics, feeding centers, and
hospitals require 40-60 L/patient/day.

Ideally, no individual dwelling should be located greater than
150 m from a water source. At any greater distance, the use of
water for hygiene is greatly diminished.

Sanitation. Camp sanitation plans should be drawn up before
refugees arrive. Because of the crucial role it plays in disease
prevention, sanitation should be an early priority for camp
planners.

Community attitudes and cultural practices regarding
sanitation and disposal of excreta are vital to the success of a
sanitation project and should be taken into careful consideration.

All efforts should be made to separate garbage and human waste
from water and food supplies. Excreta should be contained within a
specific area. Defecation fields may be used as a short-term
measure until a more appropriate sanitation system can be
implemented. This is particularly suitable in hot, dry climates.

The design and installation of latrines should also take into
consideration the attitudes and practices of the refugee
population. Latrines should be located so as to remove the
possibility of contamination of the water source.

Latrines that are poorly maintained will not be used. For this
reason, personal or family latrines are the best solution. However,
limitations on building supplies, money, and space may make this
impossible. If communal latrines are to be used, no more than 20
people should share one latrine and responsibility for maintaining
cleanliness should be clearly assigned.

Breast-feeding. Breast-feeding is an effective measure for
preventing diarrheal illness among infants. Exclusive
breast-feeding for the first 4-6 months of a baby's life, and
continued breast-feeding until the child is 2 years of age, should
be encouraged through educational campaigns targeted at pregnant
and lactating women. Distribution of milk products should be
restricted, and feeding bottles should never be distributed within
a camp (see "Nutrition").

Personal hygiene. Community health education should reinforce the
importance of handwashing with soap and of general domestic and
personal hygiene, in particular safe food-handling practices. Soap
should be made readily available by relief agencies.

Case management
Assessment (see "Patient Assessment"). An adequate history should
be taken from the patient or the patient's family. The duration of
illness; quantity, frequency, and consistency of stool; presence or
absence of blood in the stool; frequency of vomiting; and the
presence of fever or convulsions should be assessed.

Careful monitoring of the patient's weight and the signs of
dehydration throughout the course of therapy will help assess the
adequacy of rehydration. Adults with acute, dehydrating diarrhea
should be carefully assessed by a physician to rule out cholera.

Management of patients. In the camp setting, all patients with
diarrhea should be encouraged to report to a clinic or health post
for assessment, advice on feeding, fluid intake, and diarrhea
prevention. The treatment of dehydration should always be initiated
in the clinic. Ideally, a central clinic should be supplemented
with several small ORT centers in the camp, staffed by trained
community health workers.

Prevention of dehydration. Case management should focus on the
prevention of dehydration under two sets of circumstances: a) when
a patient with diarrhea shows no signs of dehydration, b) when a
patient has already been treated for dehydration in the ORT corner
and is being released from medical care. Management of patients in
these situations includes the following.
ORS. Mothers should be shown how to mix and give ORS and initially
be given a 2-day supply. The amount to be given at home is as
follows.

Children less than 2 years old: 50-100 mL (1/4 to 1/2 large

of ORS solution after each stool.

Older children: 100-200 mL after each stool.

Adults: As much as they want; however, dehydrated adults
who

fail to respond promptly to ORS should be reassessed to exclude
cholera.

Increased fluids. Patients should be instructed to increase their
normal intake of fluids. Any locally available fluids known to
prevent dehydration, especially those that can be prepared in the
home (e.g., cereal-based gruels, soup, and rice water), should be
encouraged. Soft drinks are not recommended because of their high
osmolality.

Continued feeding. Infants who are breast-fed should continue to
receive breast milk. If an infant is receiving milk formula in a
feeding center, the milk should be diluted with an equal volume of
clean water until the diarrhea stops.

For children greater than 4-6 months of age:

Give freshly prepared foods, including mixes of cereal and

beans or cereal and meat, with a few drops of vegetable oil added.

Offer food every 3-4 hours or more often for very young

children.

Encourage the child to eat as much as he or she wants.

After the diarrhea stops, give one extra meal each day for

a week.

Monitor condition. The mother should be advised to return to the
clinic with the child if he/she continues to pass many stools, is
very thirsty, has sunken eyes, has a fever, or does not generally
seem to be getting better.

Management of the dehydrated patient

Every health center in a refugee camp should have an area
allocated for supervised oral rehydration (see "Guidelines for
Rehydration Therapy"). Staff assigned to this activity need to be
well-trained in the assessment and treatment of the dehydrated
patient. Individual patients should be monitored to determine
whether the recommended doses are adequate for their needs or
whether rehydration proceeds faster than is expected.

For babies who are unable to drink but are not in shock, a
nasogastric tube can be used to administer ORS solution at the rate
of 15 mL/kg body weight/hour. For infants in shock, a nasogastric
tube should be used only if IV equipment and fluids are not
available.

Reassessment. The patient's hydration status should be reassessed
after 3-4 hours, and treatment continued according to the degree of
dehydration at that time. Note: If the child is still dehydrated,
rehydration should continue in the center. The mother should offer
the child small amounts of food.

If the child is less than 12 months of age, the mother should
be advised to continue breast-feeding. If the child is not being
breast-fed, 100-200 mL of clean, plain water should be given before
continuing the ORS. Older children and adults should consume plain
water as often as they wish throughout the course of rehydration
with ORS solution.

Nutritional maintenance. Infants should resume feeding as outlined
above. For children greater than 4-6 months old and adults, feeding
should begin as soon as the appetite returns. Energy-rich, easily
digestible foods will help maintain their nutritional status. There
is no reason to delay feeding until the diarrhea stops and there is
no justification for "resting" the bowel through fasting. Note:
Children enrolled in SFPs or TFPs who develop diarrhea with
dehydration should be fed HEM diluted with ORS in a ratio of 1:1,
alternating with plain ORS. The overall volume of fluid should be
calculated according to the child's weight and degree of
dehydration.

Use of chemotherapy. Antimicrobial drugs are contraindicated for
the routine treatment of uncomplicated, watery diarrhea. Specific
indications for their use include:

Cholera.

Shigella dysentery.

Amoebic dysentery.

Acute giardiasis.
For specific recommendations see "Cholera" and "Dysentery".
Anti-diarrheal agents are contraindicated for the treatment of

diarrheal disease. Stimulants, steroids, and purgatives are not
indicated for treatment of diarrheal disease and may produce
adverse effects.

Surveillance for Diarrheal Diseases

All health facilities that serve the refugee population should
maintain case records of diarrheal diseases as part of the routine
HIS. Records should include the degree of dehydration at the time
of presentation. Case definitions should be standardized. Dysentery
cases should be recorded as a separate category.

Any increase in the number or severity of cases, change in the
type of diarrhea, rise in diarrhea-specific mortality, or change in
the demographic breakdown of the cases should be reported. A case
definition for cholera should be established for the purpose of
surveillance. Any suspected cholera cases should be reported
immediately.

Sample case definitions for cholera and dysentery are provided
below.

Cholera

Identification of the pathogen by laboratory culture is
necessary to confirm the presence of cholera. Initially, rectal
swabs of patients with suspected cholera should be transported to
the laboratory in Cary-Blair transport medium (see Collecting,
Processing, Storing and Shipping Diagnostic Specimens in Refugee
Health-Care Environments *). The laboratory should determine the
antibiotic sensitivity of the cultured strain. Once an outbreak is
confirmed, it is not necessary to culture every case. Additionally,
it is not necessary to wait until an outbreak has been confirmed to
begin treatment and preventive measures.

In the event of an outbreak of cholera, early case-finding
will allow for rapid initiation of treatment. Aggressive
case-finding by trained community health workers should be coupled
with community education to prevent panic and to promote good
domestic hygiene.

Treatment centers should be easily accessible. Most patients
can be treated with ORS alone in the local clinic and still achieve
a CFR less than 1%. If the attack rate for cholera is high, it may
be necessary to establish temporary cholera wards to handle the
patient load. Health centers should be adequately stocked with ORS,
IV fluids, and appropriate antibiotics. Health workers must be
trained in the management of cholera.

Surveillance should be intensified and should change from
passive to active case-finding. The number of new cholera cases and
deaths should be reported daily, along with other relevant
information (e.g., age, sex, location in camp, length of stay in
camp).

Treatment

The goal of cholera treatment is to maintain the CFR at less
than 1%.

Rehydration therapy

Rehydration needs to be aggressive. However, careful
supervision is necessary to prevent fluid overload, especially when
children are rehydrated with IV fluids. Most cases of cholera can
be treated through the administration of ORS solution (see "Patient
Assessment" and "Guidelines for Rehydration Therapy". Persons with
severe disease may require IV fluid, which should be administered
following the guidelines outlined in "Diarrheal Diseases".

Antibiotics

Antibiotics reduce the volume and duration of diarrhea in
cholera patients. Antibiotics should be administered orally.
Doxycycline should be used when available in a single dose of 300
mg for adults and 6 mg/kg/day for children less than 15 years of
age. Tetracycline should be reserved for severely dehydrated
persons, who are the most efficient transmitters because of their
greater fecal losses. Tetracycline should be administered according
to the following schedule.

Adults: 500 mg every 6 hours for 72 hours

Children: 50 mg/kg/day every 6 hours for 72 hours
Chloramphenicol can be used as an alternative to tetracycline;

the dosage is the same. When tetracycline and chloramphenicol
resistance is present, furazolidone, erythromycin, or
trimethoprim-sulfamethoxazole (TMP-SMX) may be used.

Epidemiologic investigation

Epidemiologic studies to determine the extent of the outbreak
and the primary modes of transmission should be conducted so that
specific control measures can be applied. The CFR should be
monitored closely to evaluate the quality of treatment.

Case-control studies may be undertaken to identify risk
factors for infection. Environmental sampling, examination of food,
and the use of Moore swabs for sewage sampling may be useful to
confirm the results of epidemiologic studies and define modes of
transmission.

Control and prevention
Health education. The community should be kept informed as to the
extent and severity of the outbreak, as well as educated on the
ease and effectiveness of treatment. Emphasis should be placed on
the benefits of prompt reporting and early treatment. The community
should be advised about suspected vehicles of transmission. The
need for good sanitation, personal hygiene, and food safety should
be stressed. Health workers involved in treating cholera patients
need to observe strict personal hygiene, by washing their hands
with soap after examining each patient. Smoking should be
prohibited in cholera wards and clinics.

Water supply. Any water supplies implicated through epidemiologic
studies should be tested. Any contaminated water sources should be
identified and access to those sources cut off. Alternative sources
of safe drinking water should be identified and developed as a
matter of urgency.

Food safety. Community members should be informed of any food item
that has been implicated as a possible vehicle of transmission.
Health education messages regarding food preparation and storage
should be disseminated.

During an outbreak, feeding centers should be extremely
vigilant in the preparation of meals because of the potential for
mass infection. Food workers should have easy access to soap and
water for handwashing. Food workers should always wash their hands
after defecating, and any food worker who is experiencing diarrhea
should be prohibited from working.

Chemoprophylaxis. Mass chemoprophylaxis is not an effective
cholera control measure and is not recommended. Although the WHO
Guidelines for Cholera Control suggest that chemoprophylaxis may be
justified for closed groups (such as refugee camps), CDC studies
indicate that focusing on other preventive activities (i.e.,
providing an adequate water supply, improving camp sanitation, and
providing adequate and prompt treatment) results in a more
effective use of resources. If resources are adequate and
transmission rates are high (greater than 15%), consideration
should be given to providing a single dose of doxycycline to
immediate family members of diagnosed patients.

Vaccines. Currently available vaccines are not recommended for the
control of cholera among refugee populations. The efficacy of these
vaccines is low and the duration of protection provided is short.
Vaccination campaigns divert funds and personnel from more
important cholera control activities and give refugee and
surrounding populations a false sense of security.

Dysentery

When possible, patients presenting with signs and symptoms of
dysentery should have stool specimens examined by microscopy to
identify Entamoeba histolytica. Care should be taken to distinguish
large white cells (a nonspecific indicator of dysentery) from
trophozoites. Amebic dysentery tends to be misdiagnosed.

Shigellosis

If a microscope is unavailable for diagnosis, or if definite
trophozoites are not seen, persons with bloody diarrhea should be
treated initially for shigellosis. Appropriate treatment with
antimicrobial drugs decreases the severity and duration of
dysentery caused by Shigella and reduces the duration of pathogen
excretion. The selection of an antimicrobial treatment regimen is
often complicated by the presence of multiresistant strains of
Shigella. The choice of a first-line drug should be based on
knowledge of local susceptibility patterns. If no clinical response
occurs within 2 days, the antibiotic should be changed to another
recommended for that particular strain of shigellosis. If no
improvement occurs after an additional 2 days of treatment, the
patient should be referred to a hospital or laboratory for stool
microscopy. At this stage, a diagnosis of resistant shigellosis is
still more likely than amebiasis.

Drugs of choice. Treatment guidelines for shigellosis are listed
below.

50 mg/kg/day in four divided doses for 5 days.
The fluoroquinolones (e.g., ciprofloxacin and ofloxacin) are

highly effective for the treatment of shigellosis, but are
expensive and have not yet been approved for treatment of children
or pregnant or lactating women with shigellosis.

Because multiresistant strains of Shigella have become
widespread and because Shigella strains can rapidly acquire
resistance in endemic and epidemic settings, it is advisable that
periodic antibiotic susceptibility testing be performed by a
reference laboratory in the region. Note: WHO does not recommend
mass prophylaxis or prophylaxis of family members as a control
measure for shigellosis.

Amebiasis and giardiasis

Treatment for amebiasis or giardiasis should not be considered
unless microscopic examination of fresh feces shows amebic or
Giardia trophozoites, or two different antibiotics given for
shigellosis have not resulted in clinical improvement.

Knowledge of the epidemiology of transmission, including local
vectors, is essential to a malaria control effort. Information
regarding the local epidemiology may be available from the MOH,
WHO, and regional health authorities. In certain instances, a
vector survey may need to be done. The national malaria control
program or WHO staff are often able to conduct such surveys.

Information on previous exposure can be obtained from the
refugees themselves, or more detailed information on previous
exposure to specific species can be obtained through international
channels via WHO.

Within a camp, the proportion of fever illness attributable to
malaria at a particular time can be determined by obtaining thick
and thin blood smears from a sample of consecutive clinic patients
with a history of recent fever (e.g., 50 children less than 5 years
of age). The malaria infection prevalence rate among these patients
can then be compared with a control group that is free of the signs
and symptoms of malaria.

Laboratory examination will determine whether malaria illness
is caused by Plasmodium falciparum or Plasmodium vivax.
Control of Transmission

Control of malaria transmission may be achieved through a
combination of the following strategies.
Personal protection. The use of protective clothing,
insecticide-impregnated bed nets, and insect repellents will help
limit human exposure to malaria-infected mosquitoes.

Residual insecticides. Periodic spraying of the inside surfaces of
permanent dwellings may reduce transmission. The use of residual
insecticides, however, may be toxic to those involved in spraying
and can also be detrimental to the environment. Spraying can be
expensive and time consuming. Careful consideration should be given
to the technical aspects of spraying, local vector behavior and
susceptibility, personnel training, safety, and community
motivation before undertaking such a program.

Source reduction. The elimination of breeding sites by draining or
filling may reduce the density of vectors in the area. Knowledge of
the local vectors is essential to ensure that source reduction
efforts are effectively targeted.
Ultra low-volume insecticide spraying. Adult mosquitoes may be
killed through frequent fogging with nonresidual insecticides.
Fogging is generally repeated on a daily basis.

Gametocidal drug use. Gametocidal drugs (e.g., primaquine) are not
generally recommended for use in refugee camps.

Selection of control strategies will depend upon the local
epidemiologic factors, availability of resources, and environmental
and cultural factors.

Case Management
Case definition. Malaria infection is defined as the presence of
malaria parasites in the peripheral blood smear. Malaria illness is
defined as the presence of "malaria signs and symptoms" in the
presence of malaria infection. The signs and symptoms of malaria
typically include fever, chills, body aches, and headache.

Diagnosis. If possible, a thick blood smear and Giemsa stain
should be the basis for the diagnosis of malaria. These smears will
also provide the basis for transmission surveillance in camps or
geographic areas. If the patient load exceeds the capability of the
laboratory to perform thick smears on all suspected cases, a system
of microscopic diagnosis for a percentage of suspected cases should
be established. When diagnoses are made by locally trained
microscopists in small field laboratories, a randomly selected
sample of both positive and negative slides should be sent to a
reference laboratory for verification in order to maintain quality
control.

When laboratory facilities are not available, clinical
symptoms (paroxysmal fever, chills, sweats, and headache) and signs
(measured fever) are the best predictors of malaria infection. In
situations in which year-round high malaria endemicity has been
established, all episodes of fever illness can be assumed to be
caused by Plasmodium falciparum. However, health workers should
bear in mind other causes of fever, including pneumonia, ALRI, or
meningitis. In areas where transmission is highly seasonal, surveys
should be conducted each year at the beginning of the high
transmission season.

The presence of Plasmodium on blood smears does not prove that
malaria is the cause of febrile illness, even in areas where
malaria is highly prevalent. Other causes should be considered and
ruled out.

Treatment with chemotherapy. In areas without chloroquine
resistance, the oral regimen of chloroquine usually employed in the
treatment of uncomplicated attacks of malaria is as follows:

Adults: A total dose of 1,500 mg chloroquine (approximately

25 mg/kg body weight) should be given during a 3-day period. This
can be given as 600 mg, 600 mg, and 300 mg at 0, 24, and 48 hours,
respectively.

Pregnant women: Pregnant women with malaria should be

treated aggressively using the regimen for adults. Chloroquine is
safe during pregnancy. (Quinine is also safe although pregnant
women receiving IV-administered quinine should be monitored
carefully for hypoglycemia.)

Children: A total dose of 25 mg/kg body weight chloroquine

should be given during a 3-day period. This can be administered as
10 mg/kg, 10 mg/kg, and 5 mg/kg body weight at 0, 24 and 48 hours,
respectively.

In areas where the likelihood of reinfection is low,
consideration may be given to supplementation of chloroquine
treatment with primaquine for persons infected with Plasmodium
vivax.

Adults: 15 mg daily for 14 days.

Children: 0.3 mg/kg/day.
Among populations in which severe glucose-6-phosphate

dehydrogenase (G-6-PD) deficiency is common (notably among Asians),
however, primaquine should not be administered for greater than 5
days. Administration of primaquine for longer periods may result in
life-threatening hemolysis. Whenever possible, persons needing
primaquine should first have a blood test for G-6-PD deficiency.

When laboratory analysis is performed, the first dose of
chloroquine should be administered when the blood smear is taken.
The patient should be instructed to return the second day for the
results of the smear. If the smear is positive, chemotherapy should
be continued. If the smear is negative and the patient remains
febrile, other causes of fever should be identified.

If supervised therapy during a 3-day period is not possible,
the first dose of chloroquine should be given under supervision and
the additional doses may be given to the patient with appropriate
instructions.

Patients who remain symptomatic longer than 3 days into
therapy should have a repeat thick smear examined. Alternative
therapy should be instituted if the degree of parasitemia has not
diminished markedly by this time.

In areas with chloroquine resistance, treatment of patients
may be the same as in areas of chloroquine-sensitive malaria; or
may include an alternative first-line drug. Additional care in the
follow-up of patients is required.

If the patient continues to have symptoms of malaria after

48-72 hours from the start of recommended chloroquine treatment,
the patient should be treated with a second-line drug.

The choice of an alternative drug depends on the

availability of the drugs and the relative sensitivity of the
parasites. Possible alternative drugs include sulfa drugs in
combination with pyrimethamine (Fansidar, Maloprim), tetracycline,
quinine, and newer drugs such as mefloquine. Use of alternative
drugs should be consistent with national malaria control policies
in the host country.

Fever control. Antipyretics (i.e., acetaminophen, paracetamol) and
anticonvulsives are often necessary for the care of the patient
with malaria.

Children with high fevers should be frequently sponged with
tepid water. Patients should increase their intake of fluids as the
febrile illness will most likely be accompanied by mild
dehydration. Patients with signs of moderate dehydration should be
given ORS.

Chemoprophylaxis

During epidemics (seasons of high rates of transmission),
malaria chemoprophylaxis should be considered for the following
high-risk groups:

Children less than 5 years of age, especially those

suffering from malnutrition, anemia, or other debilitating
diseases.

Pregnant women.

Other groups that are at increased risk for complications
of

malaria illness due to compromised health status.

The decision to provide chemoprophylaxis to high-risk persons
should be based upon the capabilities of the health-care system to
accomplish the following:

At-risk persons can be readily identified and assembled.

Follow-up can be assured.

Sufficient personnel and medication are available to ensure

regular administration of services.

The parasite is known to be generally sensitive to the drug

used.

Administration of chemoprophylaxis to high-risk groups can be
logistically difficult and may be too great a strain on the
capacities of the health-care system to be feasible.

Expatriates working in an endemic area should be on weekly
chloroquine (300 mg chloroquine base) during the entire period of
exposure and for an additional 6 weeks after leaving the area. In
areas where chloroquine resistance is documented, prophylaxis with
mefloquine is recommended (250 mg weekly dose).

Severe malaria

Severe malaria is considered a medical emergency and demands
prompt and specific medical care. Signs and symptoms of severe
malaria include:

may be present in cerebral malaria, include drowsiness, mental
confusion, coma, and seizures.
Management of severe malaria. The following guidelines for the
management of severe malaria are based upon those prepared by the
MOH in Malawi.

Outpatient setting. If severe malaria is diagnosed in an
outpatient setting, the patient should be referred for
hospitalization. However, treatment should begin immediately and
not be delayed until the patient has been transferred.

If the patient can swallow, sulfadoxine-pyrimethamine (SP)
tablets (500 mg-25 mg) should be administered orally in the
following doses according to the patient's age.

less than 3 years old: 1/2 tablet

4-8 years old: 1 tablet

9-14 years old: 2 tablets

greater than 14 years old: 3 tablets
If the patient vomits within 30 minutes, the dose should be

repeated.

If the patient cannot swallow or is vomiting repeatedly, an IM
injection of quinine dihydrochloride (10 mg/kg) should be
administered. This can be repeated every 4 hours for two additional
doses, and every 8 hours thereafter if a long delay is anticipated
for transport of the patient to a hospital.

The patient's fever should be reduced by sponging with
lukewarm water or by using paracetamol or aspirin. Patients should
be given ORS. In a patient who cannot drink, administer 20 mL/kg
ORS with one teaspoon of glucose powder via naso-gastric tube every
4 hours.

In a child with altered consciousness or repeated convulsions,
the physician should perform a lumbar puncture if possible. If the
CSF is cloudy, treatment for meningococcal meningitis is indicated
and anti-malarial treatment should be discontinued. If a lumbar
puncture cannot be performed, treatment for meningitis should be
administered while continuing treatment for malaria.
Inpatient setting. The following tests should be performed
immediately upon admission: thick blood film, hemoglobin, blood
glucose, and lumbar puncture. If hemoglobin is below 4 g/dL, blood
grouping and cross-matching should be done.

If the patient can swallow, give oral SP as described above.
If the patient cannot swallow or has persistent vomiting, give
IV-administered quinine as follows:

An initial dose of 20 mg(salt)/kg body weight is injected

into 10 mL/kg 5% dextrose (half-strength Darrow's solution) and
infused during a 3-hour period. (If the patient has already
received quinine before admission, the initial dose should be 10
mg/kg.)

Subsequent doses of 10 mg/kg should be repeated as above

every 12 hours. In between doses of quinine, the IV fluid (10 mL/kg
during a 3-hour period) should be continued. Patients should be
switched to oral medications as soon as their conditions allow.

In the presence of signs of volume depletion, fluid (which
includes dextrose) should be administered to maintain cardiac
output and renal perfusion.

saline, since this mixture provides dextrose to prevent
hypoglycemia and less salt to leak into pulmonary and cerebral
tissues. Alternative IV fluids should be considered if this is
unavailable.

Hypoglycemia is a complicating factor in patients with
cerebral malaria and a risk factor for fatal outcome. When
possible, blood glucose levels should be monitored. Hypoglycemia
should be suspected whenever there is a deterioration in clinical
status, especially in the presence of new neurologic findings.
Hypoglycemia can be treated presumptively with 50 mL of 50% IV
dextrose.

Blood transfusion is indicated when Hb less than 4 g/dL, or
Hb less than 6 g/dL is detected and the patient has signs of heart
failure (i.e., dyspnea, enlarging liver, gallop rhythm).

The administration of steroids has an adverse effect on
outcome in cerebral malaria. Therefore, steroids are no longer
recommended.
Anemia

Most anemias caused by malaria will reverse spontaneously
after anti-malarial therapy. However, anemia may progress for
several weeks after successful treatment of severe malaria and may
require treatment.

For some patients (especially children), blood transfusion may
be lifesaving. Recent studies indicate that blood transfusion
should be given for Hb less than 4 g/dL or Hb less than 6 g/dL in
the presence of symptoms of respiratory distress. Because of the
potential for HIV or hepatitis B transmission, blood transfusion
should be reserved for medical emergencies for which no alternative
treatment exists. Facilities for screening blood for HIV antibodies
are rare in refugee camps. Whenever feasible, patients requiring
transfusion should be transferred to hospitals where such
facilities exist.

The anemia of malaria is not associated with iron loss, and
replacement is helpful only if a coexisting iron deficiency exists.
Folic acid replacement may be helpful during the recovery period
when rapid erythrocyte replacement occurs.
Renal failure

Replacement of fluid losses (sweat, vomit, and diarrhea) is
recommended to prevent renal failure. If renal failure is
suspected, strict monitoring of fluid intake and output is
necessary.

In the presence of oliguria, a fluid challenge followed by
furosemide injection can help to differentiate acute renal failure
from prerenal causes. If renal failure is demonstrated, fluid
intake must be limited to daily replacement of insensible loss plus
urine/vomitus volume in the previous 24 hours. Protein intake
should be limited to less than 30 mg/day, and all drug doses
should be adjusted for renal failure.

Selected Reading

Ministry of Health. Malawi guidelines for the management of
malaria. Malawi, October 1991.

The TB control program should establish a policy covering
areas of case definition, case-finding, treatment regimen, and the
supervision of chemotherapy. This policy should be agreed upon and
adhered to by all organizations and agencies providing health
services to the refugees.

During the emergency phase of a refugee relief operation, TB
activities should be limited to the treatment of patients who
present themselves to the health-care system and in whom tubercle
bacilli have been demonstrated by sputum smear examination.

Control of transmission
Target population. Because of the limited resources available,
efforts to control transmission of TB within a refugee settlement
should focus on the primary sources of infection, i.e., those
patients for whom microscopic analysis of sputum smears
demonstrates the presence of acid-fast bacilli (AFB). (Specimens
should be stained using the Ziehl-Neelsen method with the results
graded quantitatively.)

Case identification. Passive case-finding will be most efficient
in the refugee setting. Patients with respiratory symptoms (chest
pain, cough) of greater than 3 weeks' duration, hemoptysis of any
duration, or significant weight loss should have a direct
microscopic examination of their sputum for AFB. If the sputum
smear is negative for AFB but pulmonary TB is still suspected, the
patient should be given a 10-day course of antibiotics and then be
re-examined after 2-4 weeks. Specific anti-TB chemotherapy should
not begin unless the presence of AFB has been confirmed.
Symptomatic family members of an identified patient should also
have sputum specimens examined.

Children who show signs and symptoms compatible with TB and
who are either: a) a close contact of a patient with a confirmed
case of TB, or b) tuberculin skin-test positive (in the absence of
a BCG vaccination scar) should undergo a full course of anti-TB
treatment if they do not respond to an appropriate regimen of
alternative antibiotics.

Case management. The selection of a first-line chemotherapy
regimen should generally be consistent with the national policy set
forth by the host country MOH. However, it should be recognized
that the crowded conditions of a refugee camp may foster an
abnormally high rate of transmission. Additionally, uncertainty
exists regarding the duration of stay in the country of asylum, and
it may be more difficult to maintain adherence to an extended
therapy regimen. Short-course therapy (6 months) should be
considered for use in a refugee camp even when the national policy
prescribes a longer course of treatment, provided the additional
expense is not prohibitive.

Before enrolling refugees in a TB treatment program,
consideration should be given to the stability of the populations
and the capacity of the health-care program to supervise therapy
and to follow-up patients who do not adhere to treatment.
Administration of anti-TB drugs to persons in whom adherence is
likely to be sporadic will foster increased drug resistance in that
population.

The following drugs are used for the treatment of TB with
chemotherapy: isoniazid, rifampin, pyrazinamide, streptomycin,
ethambutol, and thiacetazone. The selection of a particular
treatment regimen must take into consideration the organism
susceptibility, cost, and duration of therapy. The decision
regarding implementation of a specific therapeutic regimen will
generally be made by the UNHCR in consultation with the MOH of the
host government.

Case-holding. Whenever possible, chemotherapy should be observed
by a health-care provider, especially during the first 2-3 months
of treatment. Treatment efficacy should be assessed through a
series of sputum smears. Patients participating in observed therapy
who do not respond to treatment and whose sputum smears remain
positive for AFB after 2 months should be reviewed by a physician
and should begin a second-line treatment regimen.

Enrolling TB patients in a SFP may improve adherence to the
treatment regimen and acts as a point of contact for follow-up.

The success of a TB control program depends on good management
and close supervision. The responsibilities of staff assigned to
the program need to be clearly defined, adequate records of patient
progress should be maintained, and a system to follow-up patients
who do not adhere to treatment should be established. The
cooperation of the community is essential for success. A community
education program should be established to help ensure adherence.

Prevention

Preventive chemotherapy for subclinical TB usually does not
play a substantial role in TB control in a refugee camp. However,
immediate family members of active TB patients should be examined
for active TB and referred for treatment. This is particularly
important for young children.

BCG vaccination should be administered as part of the
comprehensive immunization schedule and not as a separate TB
control activity. BCG vaccination is contraindicated for persons
with symptomatic HIV infection, but can be administered to
asymptomatic persons.

An epidemic is an unusually large or unexpected increase in
the number of cases of a certain disease for a given place and time
period. The general conditions of many refugee settlements (i.e.,
overcrowding, poor water and sanitation, inadequate rations) create
an environment conducive to epidemics of infectious diseases. In
the event of a suspected outbreak, an epidemiologic investigation
should be conducted as quickly as possible.

Purpose

Epidemiologic investigations are conducted in order to:

Confirm the threat or existence of an epidemic and identify

the causative agent, its source and mode of transmission.

Determine the geographic distribution and the public health

impact of an epidemic, identifying those groups or persons who are
at highest risk for disease.

Assess local response capacity and identify the most

effective control measures.

Preparations

Each camp should have an established HIS with standardized
reporting practices. This will allow for prompt recognition of and
rapid response to an epidemic.

An accurate assessment of available laboratory facilities is
necessary in order to identify appropriate sites for microbiologic
confirmation of an epidemic and to address deficiencies that may
hamper an investigation.

Appropriate specimen containers and transport media should be
procured. Arrangements should be made to meet the need for
additional technical support.

A recognized administrative and reporting structure should be
established, with a clear chain of command and delegation of
responsibility. Lines of command should be well defined, and
specific persons should be assigned responsibility for addressing
the media and acting as liaisons to the camp leaders and the
refugee population.

Current maps showing settlements, water sources, transport
routes, and health facilities should be made available to
investigators.

Conducting the investigation
Determining the existence of an epidemic. An established HIS will
allow for prompt recognition and confirmation of an epidemic. The
need for routine health surveillance in a refugee camp cannot be
overstated. Even if such a system is firmly in place and
implemented, reports of an epidemic may be the result of
artifactual causes, i.e., changes in reporting practices, an
increased interest in a particular disease, a change in diagnostic
methods, the arrival of new health staff, or an increase in the
number of health facilities.

Confirming the diagnosis. The diagnosis of an epidemic disease
should be confirmed using standard clinical or laboratory
techniques. However, once the presence of an epidemic is
established, it is not necessary to confirm the diagnosis for each
person before treatment. Ongoing laboratory confirmation of a
sample of cases is generally sufficient.

Determining the number of cases. A workable case definition must
be established in order to determine the scope of the outbreak. The
sensitivity and specificity of the case definition depend upon:

The usual apparent-to-inapparent case ratio.

Whether pathognomonic signs and symptoms exist.

The need for laboratory support for diagnosis.

The accessibility of cases.

The level of expertise of available health personnel.

The amount of subjectivity involved in the diagnosis.
A case-finding mechanism should be established. The dynamics

of this system will depend upon the disease being investigated and
the specific attributes of the camp involved. Case-finding will be
facilitated if a cadre of refugee community health workers has been
identified and trained. The presence of an active camp health
committee will also promote effective case-finding.
Time, place, and person. Certain information should be collected
from each patient, or from their families, and recorded in a
register. This should include:

The date (and perhaps the time) of onset of symptoms.

The length of time between arrival in camp and the onset of

symptoms.

Patient's age and gender.

Place of residence.

Ethnic group (if applicable).

Determining who is at risk. The data collected from patients
should be used in an ongoing analysis to determine who is at
greatest risk and to target specific interventions most
effectively.

Prepare a graph showing the number of cases per day. This
"epidemic curve" will indicate the point at which the outbreak
first occurred, the magnitude of the outbreak, the incubation
period, and possible modes of transmission.

Using a current map of the camp, mark the residence or section
of the camp of each case as it is reported. This will allow
investigators to identify clusters of patients and may help to
pinpoint a common source of infection.

A breakdown of cases by age, gender, length of stay in camp,
vaccination status, if pertinent, and perhaps ethnic group will
enable investigators to identify those groups or persons who are at
highest risk for infection.

Testing a hypothesis. As preliminary data are collected and
analyzed, a hypothesis on the causative exposure should be
developed and tested. A case-control study and analysis will help
determine likely risk factors and sources of exposure. Laboratory
analysis of environmental samples may be used to confirm a
suspected source of infection.

Preparing a report. Meetings should be held regularly with camp
administrative officials, UNHCR and NGO representatives, local
health officials, and refugee community leaders to discuss the
evolution of the outbreak and to stress current control measures.
In some cases, a written report may be necessary before any control
and prevention efforts are undertaken. The report should include an
estimate of the magnitude and health impact of the outbreak in
numbers of projected cases and deaths. It should also include an
estimation of the need for outside assistance and supplies. A
written report will also provide a valuable record for use in
future investigations. Moreover, the written report can serve as a
useful teaching tool.

Control and prevention

As the epidemiologic investigation progresses, it is important
that decision-makers be informed as to the findings so that
appropriate control measures may be instituted. Continued disease
surveillance will determine the effectiveness of control measures.

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